MEDICARE: MICHAEL ANTHONY REISIG M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	5776190-1205	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588662639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL ANTHONY REISIG M.D.

Provider Business Mailing Address
First Line	:	340 PRINTERS PKWY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-3190
Country	:	US
Telephone Number	:	719-632-5700
Fax Number	:	719-344-7837

Provider Business Practice Location Address
First Line	:	2828 INTERNATIONAL CIR
Second Line	:	SUITE 140
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-3127
Country	:	US
Telephone Number	:	719-632-5700
Fax Number	:	719-344-7821

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	09/23/2013

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