MEDICARE: LAWRENCE J RISIGO PT

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	225100000X	Physical Therapist	PT575	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	005147	OTHER	ME	BC/BS OF MAINE

General Provider Information

NPI Number	:	1710986872
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAWRENCE J RISIGO PT

Provider Business Mailing Address
First Line	:	55 SPRING ST
Second Line	:	SUITE B
City	:	SCARBOROUGH
State	:	ME
Zip	:	04074-8926
Country	:	US
Telephone Number	:	207-396-5165
Fax Number	:	207-396-5199

Provider Business Practice Location Address
First Line	:	55 SPRING ST
Second Line	:	SUITE B
City	:	SCARBOROUGH
State	:	ME
Zip	:	04074-8926
Country	:	US
Telephone Number	:	207-396-5165
Fax Number	:	207-396-5199

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

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	03/25/2013

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