Provider Demographics
NPI:1295720779
Name:REISNER, TERRY R (MD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:R
Last Name:REISNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:ALGOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54201-1733
Mailing Address - Country:US
Mailing Address - Phone:920-487-3496
Mailing Address - Fax:
Practice Address - Street 1:427 N 12TH
Practice Address - Street 2:
Practice Address - City:PLUMMER
Practice Address - State:ID
Practice Address - Zip Code:83851-0388
Practice Address - Country:US
Practice Address - Phone:208-686-1931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43629207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F34210Medicare UPIN