Provider Demographics
NPI:1952344152
Name:REISMAN, RICHARD M (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
Last Name:REISMAN
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 1:2050 BENNETT RD
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-1253
Mailing Address - Country:US
Mailing Address - Phone:770-241-5075
Mailing Address - Fax:
Practice Address - Street 1:2050 BENNETT RD
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-1253
Practice Address - Country:US
Practice Address - Phone:770-241-5075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029937207LP2900X, 208D00000X
NY150988-1208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00351557AMedicaid
GA000351557AMedicaid
GA2021726886Medicare PIN
GA000351557AMedicaid
GA000351557AMedicaid