Provider Demographics
NPI:1588662639
Name:REISIG, MICHAEL ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:REISIG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 PRINTERS PKWY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3190
Mailing Address - Country:US
Mailing Address - Phone:719-632-5700
Mailing Address - Fax:719-344-7837
Practice Address - Street 1:2828 INTERNATIONAL CIR
Practice Address - Street 2:SUITE 140
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3127
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:719-344-7821
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5776190-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO90807782Medicaid
UT061506129008Medicaid