=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083671333
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDON D. RIESENMY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2006
-----------------------------------------------------
Last Update Date | 02/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 S CONNOR AVE
-----------------------------------------------------
City | JOPLIN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64804-1841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-782-0880
-----------------------------------------------------
Fax | 417-782-0884
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 E. CENTENNIAL STE. 13
-----------------------------------------------------
City | PITTSBURG
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-231-1068
-----------------------------------------------------
Fax | 620-231-2792
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 112406
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 04-23189
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------