Provider Demographics
NPI:1083671333
Name:RIESENMY, BRANDON D (MD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:D
Last Name:RIESENMY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E. CENTENNIAL
Mailing Address - Street 2:STE. 13
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762
Mailing Address - Country:US
Mailing Address - Phone:620-231-1068
Mailing Address - Fax:620-231-2792
Practice Address - Street 1:2001 S CONNOR AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1841
Practice Address - Country:US
Practice Address - Phone:417-782-0880
Practice Address - Fax:417-782-0884
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1124062084P0800X
KS04-231892084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208649947Medicaid
MO208649962Medicaid
KS04-23189OtherKANSAS LICENSE
MO208649947Medicaid
MO208649962Medicaid
MOG48298Medicare UPIN
KS100098150AMedicare ID - Type UnspecifiedFAMILY LIFE