Provider Demographics
NPI:1114067477
Name:RILEY, MARC THOMAS (PT)
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:THOMAS
Last Name:RILEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14905-2324
Mailing Address - Country:US
Mailing Address - Phone:607-346-7587
Mailing Address - Fax:
Practice Address - Street 1:2667 CORNING RD
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-4202
Practice Address - Country:US
Practice Address - Phone:607-739-1700
Practice Address - Fax:607-739-1792
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2011-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT0178972251X0800X
PART0031702255A2300X
NY620297762251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA117299Medicare PIN