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General NPI Number Information
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NPI Number | 1407831191
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Entity Type | Individual
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Provider Name | MICHAEL VAN RIESBERG M.D.
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Gender | Male
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Dates
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Enumeration Date | 12/14/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2411 EXECUTIVE PLAZA RD
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City | PENSACOLA
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State | FL
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Zip | 32504-8269
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Country | US
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Telephone | 850-476-0700
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Fax | 850-476-4300
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Provider Business Mailing Address
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Address Line | 2411 EXECUTIVE PLAZA RD
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City | PENSACOLA
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State | FL
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Zip | 32504-8269
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Country | US
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Telephone | 850-476-0700
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Fax | 850-476-4300
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | ME 75687
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License Number State | FL
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