Provider Demographics
NPI:1538128244
Name:RAISIS, IRENE (MD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:RAISIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4755 OGLETOWN STANTON RD
Mailing Address - Street 2:DEPARTMENT OF RADIOLOGY
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19718-2200
Mailing Address - Country:US
Mailing Address - Phone:302-733-1806
Mailing Address - Fax:302-733-1808
Practice Address - Street 1:4755 OGLETOWN STANTON RD
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-2200
Practice Address - Country:US
Practice Address - Phone:302-733-1806
Practice Address - Fax:302-733-1808
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-00031912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000112101Medicaid
300027132OtherRAILROAD MEDICARE #
F10229Medicare UPIN
300027132OtherRAILROAD MEDICARE #
DE536928X32Medicare PIN