1538264775 NPI number — DR. JESSICA SHELLEY RIEDISSER D.C.

Table of content: DR. JESSICA SHELLEY RIEDISSER D.C. (NPI 1538264775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538264775 NPI number — DR. JESSICA SHELLEY RIEDISSER D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIEDISSER
Provider First Name:
JESSICA
Provider Middle Name:
SHELLEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHELLEY
Provider Other First Name:
JESSICA
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1538264775
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1159 BRYAN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
O FALLON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63366-3459
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-240-8989
Provider Business Mailing Address Fax Number:
636-240-6889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1159 BRYAN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
O FALLON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63366-3459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-240-8989
Provider Business Practice Location Address Fax Number:
636-240-6889
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2003006354 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 185420 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 259375050 . This is a "MEDICARE INDIVIDUAL PTAN NUMBER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 0000259375050 . This is a "MEDICARE INVIDICUAL PTAN, ANOTHER FORMAT" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 696970 . This is a "ACN GROUP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 739074 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 7590746 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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