Provider Demographics
NPI:1093810012
Name:RILEY, THEODORE
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:RILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5504 RALEIGH ST
Mailing Address - Street 2:UPMC PASSAVANT HOSPITAL
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15217-1535
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5504 RALEIGH ST
Practice Address - Street 2:UPMC PASSAVANT HOSPITAL
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15217-1535
Practice Address - Country:US
Practice Address - Phone:412-521-6671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0S012711207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019732610001Medicaid
H96982Medicare UPIN
PA074623PRSMedicare ID - Type Unspecified