MEDICARE: MR. SOL REISIN MD

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	207R00000X	Internal Medicine Physician	A39697	CA
2	207RN0300X	Nephrology Physician	A39697	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	W13536	OTHER	CA	MEDICARE GROUP #
6	WA39697B	OTHER	CA	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ47484Z	OTHER	CA	BLUE SHIELD ZZZ#
2	GR0066310	OTHER	CA	GROUP MEDI-CAL #
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	110111657	OTHER	CA	RAILROAD PIN#

General Provider Information

NPI Number	:	1700844222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SOL REISIN MD

Provider Business Mailing Address
First Line	:	516 WEST ATEN ROAD
Second Line	:	SUITE 2
City	:	IMPERIAL
State	:	CA
Zip	:	92251-9805
Country	:	US
Telephone Number	:	760-355-7730
Fax Number	:	760-355-7731

Provider Business Practice Location Address
First Line	:	1550 NORTH IMPERIAL AVENUE
Second Line	:	SUITE 1
City	:	EL CENTRO
State	:	CA
Zip	:	92243-4242
Country	:	US
Telephone Number	:	760-353-4710
Fax Number	:	760-545-0244

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

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	12/19/2016

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Directions to “ MR. SOL REISIN MD” Practice Location

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