Provider Demographics
NPI:1508982299
Name:JAY RISEMAN MD LTD
Entity Type:Organization
Organization Name:JAY RISEMAN MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:A
Authorized Official - Last Name:RISEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-629-8711
Mailing Address - Street 1:2524 FARRAGUT DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-8400
Mailing Address - Country:US
Mailing Address - Phone:217-546-8711
Mailing Address - Fax:217-546-8720
Practice Address - Street 1:2524 FARRAGUT DR
Practice Address - Street 2:SUITE C
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-8400
Practice Address - Country:US
Practice Address - Phone:217-546-8711
Practice Address - Fax:217-546-8720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL148336OtherHEALTHLINK NETWORK ID
IL08400721OtherBLUECROSS BLUESHIELD
3001OtherNEIC SITE ID,NSF BAO-7
IL087768OtherHEALTH ALLIANCE
ILE80209Medicare UPIN
IL945130Medicare PIN