Provider Demographics
NPI:1215090378
Name:MOORE-RIESBECK, SUSAN MARIE (DO)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:MOORE-RIESBECK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 175
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-0175
Mailing Address - Country:US
Mailing Address - Phone:574-273-8053
Mailing Address - Fax:574-273-8056
Practice Address - Street 1:28070 COUNTY ROAD 24
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-9717
Practice Address - Country:US
Practice Address - Phone:574-273-8053
Practice Address - Fax:574-273-8056
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001290A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100366000Medicaid
IN100366000Medicaid
IN148660Medicare ID - Type UnspecifiedMEDICARE NUMBER