MEDICARE: RANDOLPH J REISTER 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	5242	SD
2	207R00000X	Internal Medicine Physician	102423	MN

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

General Provider Information

NPI Number	:	1952385114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDOLPH J REISTER MD

Provider Business Mailing Address
First Line	:	1202 9TH AVE W
Second Line	:
City	:	MOBRIDGE
State	:	SD
Zip	:	57601-1210
Country	:	US
Telephone Number	:	605-845-3582
Fax Number	:

Provider Business Practice Location Address
First Line	:	710 DIVISION ST S
Second Line	:
City	:	NORTHFIELD
State	:	MN
Zip	:	55057-2468
Country	:	US
Telephone Number	:	507-646-1494
Fax Number	:

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

Provider Enumeration Date	:	12/01/2005
Last Update Date	:	03/10/2021

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