Provider Demographics
NPI:1710986872
Name:RISIGO, LAWRENCE J (PT)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:J
Last Name:RISIGO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 SPRING ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-8926
Mailing Address - Country:US
Mailing Address - Phone:207-396-5165
Mailing Address - Fax:207-396-5199
Practice Address - Street 1:55 SPRING ST
Practice Address - Street 2:SUITE B
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-8926
Practice Address - Country:US
Practice Address - Phone:207-396-5165
Practice Address - Fax:207-396-5199
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT575225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME005147OtherBC/BS OF MAINE
MEMM2315Medicare ID - Type Unspecified