Provider Demographics
NPI:1447455019
Name:RISSE, ANA L (MD)
Entity type:Individual
Prefix:DR
First Name:ANA
Middle Name:L
Last Name:RISSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANA
Other - Middle Name:L
Other - Last Name:MATOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:109 CALIFORNIA STREET
Mailing Address - Street 2:PO BOX 577
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-0577
Mailing Address - Country:US
Mailing Address - Phone:618-985-8221
Mailing Address - Fax:618-985-4635
Practice Address - Street 1:7 S HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-3333
Practice Address - Country:US
Practice Address - Phone:618-687-3418
Practice Address - Fax:618-687-1859
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43965207Q00000X
NY244507207Q00000X
IL036.139132207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370966854002Medicaid
IL640701OtherMEDICARE - GROUP
IL036139132Medicaid
KY50032652OtherPASSPORT - NLPCC
KY7279197OtherCIGNA - NLPCC
KY138990OtherSIHO - NICC
KYK056830OtherMEDICARE KY - NICC
KY610978438WOtherHUMANA - NLPCC
KY000000778633OtherANTHEM - NICC
KY120649OtherSIHO - NLPCC