Basic Information
| Provider Information | |||||||||
| NPI: | 1205463106 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REISSIG | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 MALLARD RD | ||||||||
| Address2: | |||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435512539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142092009 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2142 N COVE BLVD | ||||||||
| Address2: | PROMEDICA TOLEDO HOSPITAL, DEPARTMENT OF RADIOLOGY | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192915992 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2020 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.