Provider Demographics
NPI:1083871586
Name:RIESS, KEVIN P (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:P
Last Name:RIESS
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 1:1101 9TH STREET NORTH
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792
Mailing Address - Country:US
Mailing Address - Phone:218-741-0150
Mailing Address - Fax:
Practice Address - Street 1:1101 9TH STREET NORTH
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792
Practice Address - Country:US
Practice Address - Phone:218-741-0150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47680-20208600000X
MN50561208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1083871586Medicaid
MN020002569Medicare PIN