Basic Information
| Provider Information | |||||||||
| NPI: | 1124133210 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RISEBERG | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 227 ST PAUL PLACE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212022001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107835858 | ||||||||
| FaxNumber: | 4107835864 | ||||||||
| Practice Location | |||||||||
| Address1: | 227 ST PAUL PLACE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212022001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107835858 | ||||||||
| FaxNumber: | 4107835864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207RX0202X | D40854 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 52343402 | 01 | CAREFIRST MD | OTHER | R8440002 | 01 | CAREFIRST DC | OTHER | 776075 | 01 | AETNA | OTHER |