Provider Demographics
NPI:1932462397
Name:RIESA, MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:RIESA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 FRIES MILL RD STE 301
Mailing Address - Street 2:
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-2016
Mailing Address - Country:US
Mailing Address - Phone:565-134-1248
Mailing Address - Fax:
Practice Address - Street 1:2301 S BROAD ST RM 112
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-3542
Practice Address - Country:US
Practice Address - Phone:215-510-2176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB09676000282N00000X
PAOS020721282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0467618Medicaid