Provider Demographics
NPI:1275532392
Name:RISAVI, BRIAN LARRY (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:LARRY
Last Name:RISAVI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 STATE ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16550-0002
Mailing Address - Country:US
Mailing Address - Phone:814-877-6139
Mailing Address - Fax:814-877-6093
Practice Address - Street 1:201 STATE ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16550-0002
Practice Address - Country:US
Practice Address - Phone:814-877-6139
Practice Address - Fax:814-877-6093
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009354L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018025310001Medicaid
PA1514333OtherGATEWAY
OH2219727OtherOH MEDICAID
PA2545956OtherAETNA
PA930092901OtherRR MEDICARE
NY00025185301OtherUNIVERA
PA108059OtherUNISON
PA212665OtherUPMC
NY02083085OtherNY MEDICAID
WV1068836OtherWEST VIRGINIA WORK COMP
PA436535OtherBLUE SHIELD
NY00025185301OtherUNIVERA
H17350Medicare UPIN