Provider Demographics
NPI:1700042710
Name:RIESTER, SCOTT M (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:RIESTER
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 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0002
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:404 W FOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007
Practice Address - Country:US
Practice Address - Phone:507-373-2384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN520442083X0100X, 207X00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNP00824262OtherRAILROAD MEDICARE
MNENROLLEDMedicaid