Provider Demographics
NPI:1568657328
Name:FRISCIA, MARISA (MD)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:FRISCIA
Suffix:
Gender:F
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:PO BOX 61
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05250-0061
Mailing Address - Country:US
Mailing Address - Phone:802-375-6566
Mailing Address - Fax:802-375-6828
Practice Address - Street 1:200 RICHMOND AVE E STE 1
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4652
Practice Address - Country:US
Practice Address - Phone:217-234-7000
Practice Address - Fax:217-234-7011
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042.0010507207R00000X
VT042-0010507207R00000X
IL036147975207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009307Medicaid
VT1009307Medicaid
VTF99703Medicare UPIN
VTF99703Medicare UPIN