Provider Demographics
NPI:1982758439
Name:RISNER, PAUL JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JOSEPH
Last Name:RISNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 GREENVIEW LANE
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-3213
Mailing Address - Country:US
Mailing Address - Phone:847-419-0704
Mailing Address - Fax:
Practice Address - Street 1:34157 N ROUTE 45
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-1715
Practice Address - Country:US
Practice Address - Phone:847-223-9020
Practice Address - Fax:847-223-6247
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01607186OtherBC BS
IL385520Medicare ID - Type Unspecified
46769Medicare UPIN