Provider Demographics
NPI:1437427614
Name:REISENAUER, PHIL J (MT)
Entity type:Individual
Prefix:MR
First Name:PHIL
Middle Name:J
Last Name:REISENAUER
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 OSBORN DR
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-3960
Mailing Address - Country:US
Mailing Address - Phone:701-225-3906
Mailing Address - Fax:
Practice Address - Street 1:188 OSBORN DR
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-3960
Practice Address - Country:US
Practice Address - Phone:701-225-3906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND93172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker