Provider Demographics
NPI:1033194105
Name:RIEDEL, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:RIEDEL
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 1:25 WELLS ST
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-2922
Mailing Address - Country:US
Mailing Address - Phone:401-729-2191
Mailing Address - Fax:401-729-2517
Practice Address - Street 1:111 BREWSTER ST
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4400
Practice Address - Country:US
Practice Address - Phone:401-729-2191
Practice Address - Fax:401-729-2517
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD05718207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9001767Medicaid
MA110065100AMedicaid
RI007061101OtherMEDICARE PTAN
RI9001767Medicaid