Provider Demographics
NPI:1467404640
Name:REISS, WARREN K (MD)
Entity Type:Individual
Prefix:DR
First Name:WARREN
Middle Name:K
Last Name:REISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6309
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46660-6309
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:921 N LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:CULVER
Practice Address - State:IN
Practice Address - Zip Code:46511-1207
Practice Address - Country:US
Practice Address - Phone:574-842-3327
Practice Address - Fax:574-842-4330
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026349A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100173440Medicaid
IN15D0356500OtherCLIA
IN207Q000000XOtherTAXONOMY
IN000000083972OtherBCBS
IN207Q000000XOtherTAXONOMY
INM400061609Medicare PIN
IN000000083972OtherBCBS
INB29146Medicare UPIN