Provider Demographics
NPI:1174505366
Name:RISEMAN, JAY ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:ALAN
Last Name:RISEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:
Other - Last Name:RISEMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:901 E 104TH ST
Mailing Address - Street 2:MS 400S
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131
Mailing Address - Country:US
Mailing Address - Phone:816-502-8752
Mailing Address - Fax:816-932-9670
Practice Address - Street 1:12300 METCALF AVE
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213-1324
Practice Address - Country:US
Practice Address - Phone:816-932-2239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080219502086H0002X
KS04-341162086H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086H0002XAllopathic & Osteopathic PhysiciansSurgeryHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1174505366Medicaid
KS200852540BMedicaid
MO1174505366Medicaid