Basic Information
| Provider Information | |||||||||
| NPI: | 1275532392 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RISAVI | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | LARRY | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 201 STATE ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165500002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148776139 | ||||||||
| FaxNumber: | 8148776093 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 STATE ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165500002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148776139 | ||||||||
| FaxNumber: | 8148776093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 03/28/2013 | ||||||||
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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 | 207P00000X | OS009354L | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0018025310001 | 05 | PA | MEDICAID | 1514333 | 01 | PA | GATEWAY | OTHER | 2219727 | 01 | OH | OH MEDICAID | OTHER | 2545956 | 01 | PA | AETNA | OTHER | 930092901 | 01 | PA | RR MEDICARE | OTHER | 00025185301 | 01 | NY | UNIVERA | OTHER | 108059 | 01 | PA | UNISON | OTHER | 212665 | 01 | PA | UPMC | OTHER | 02083085 | 01 | NY | NY MEDICAID | OTHER | 1068836 | 01 | WV | WEST VIRGINIA WORK COMP | OTHER | 436535 | 01 | PA | BLUE SHIELD | OTHER |