Provider Demographics
NPI:1205802998
Name:REISENAUER, CHRISTIN S (MD)
Entity type:Individual
Prefix:
First Name:CHRISTIN
Middle Name:S
Last Name:REISENAUER
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:PO BOX 9583
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-0177
Mailing Address - Country:US
Mailing Address - Phone:208-882-8369
Mailing Address - Fax:208-882-1887
Practice Address - Street 1:405 STYNER AVE
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-9394
Practice Address - Country:US
Practice Address - Phone:208-882-8369
Practice Address - Fax:208-882-1887
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6554174400000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003901200Medicaid
WA8235863Medicaid
WA8235863Medicaid
ID11303201Medicare PIN
WAP00605740Medicare PIN
WAG8891823Medicare PIN
IDF25673Medicare UPIN
WA8859552Medicare PIN