Provider Demographics
NPI:1861589558
Name:RIESS, GERALD T (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:T
Last Name:RIESS
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 1:1001 BELLEFONTAINE AVE
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2800
Mailing Address - Country:US
Mailing Address - Phone:419-998-4575
Mailing Address - Fax:419-998-4586
Practice Address - Street 1:1005 BELLEFONTAINE AVE STE 350
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2885
Practice Address - Country:US
Practice Address - Phone:419-998-8200
Practice Address - Fax:419-998-8203
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010526462084N0400X
OH351238732084N0400X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2833149Medicaid
OR500628221Medicaid
ORR156261Medicare PIN
MI2833149Medicaid
MI0H16144Medicare PIN
MI2833149Medicaid