Provider Demographics
NPI:1184721219
Name:VANRIESSEN, JAMES EREK (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:EREK
Last Name:VANRIESSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:3805 S KANSAS EXPY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-6989
Practice Address - Country:US
Practice Address - Phone:417-269-0269
Practice Address - Fax:417-269-0279
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004001491207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207274101Medicaid
198541OtherBLUE CROSS OF MO
I25191Medicare UPIN
MOP00448081Medicare PIN
MO207274101Medicaid