Basic Information
| Provider Information | |||||||||
| NPI: | 1578740692 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHELLE REISNER MD, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 729 | ||||||||
| Address2: | |||||||||
| City: | TENAFLY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076700729 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 196 JEWETT AVE | ||||||||
| Address2: | |||||||||
| City: | JERSEY CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 073041804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2013323354 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2008 | ||||||||
| LastUpdateDate: | 01/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | CHAUDHARY | ||||||||
| AuthorizedOfficialFirstName: | YOGINI | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLER | ||||||||
| AuthorizedOfficialTelephone: | 7323211100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3914500 | 05 | NJ | MEDICAID |