Provider Demographics
NPI:1154346948
Name:MARK A RISEN, DPM,
Entity type:Organization
Organization Name:MARK A RISEN, DPM,
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:RISEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:270-789-4342
Mailing Address - Street 1:1003 OLD GREENSBURG RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-2571
Mailing Address - Country:US
Mailing Address - Phone:270-789-4342
Mailing Address - Fax:270-465-3305
Practice Address - Street 1:1003 OLD GREENSBURG RD
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-2571
Practice Address - Country:US
Practice Address - Phone:270-789-4342
Practice Address - Fax:270-465-3305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00216213E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY80002165Medicaid
KY80002165Medicaid
KY1212820001Medicare NSC
KY=========OtherTAX ID