Basic Information
| Provider Information | |||||||||
| NPI: | 1053391490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REISMAN | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | BRADLEY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705357445 | ||||||||
| Practice Location | |||||||||
| Address1: | 4222 FAIRBANKS DR | ||||||||
| Address2: | |||||||||
| City: | OAKWOOD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305662811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705346053 | ||||||||
| FaxNumber: | 7705346695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 07/19/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 042406 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 341309 | 01 | GA | WELLCARE | OTHER | 52595494 | 01 | GA | BCBS | OTHER | 10045366 | 01 | GA | AMERIGROUP | OTHER | 000716878A | 05 | GA | MEDICAID | 4969623 | 01 | GA | CIGNA | OTHER | 5218658 | 01 | GA | AETNA PPO | OTHER | 0100333 | 01 | GA | UNITED HEALTHCARE | OTHER | 80109236 | 01 | GA | RR MEDICARE-GRP # CC4177 | OTHER |