Provider Demographics
NPI:1114311214
Name:RILEY MEDICAL CORPORATION
Entity Type:Organization
Organization Name:RILEY MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RILEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-472-6206
Mailing Address - Street 1:543 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07504-2205
Mailing Address - Country:US
Mailing Address - Phone:973-742-6206
Mailing Address - Fax:973-742-6206
Practice Address - Street 1:543 14TH AVE
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07504-2205
Practice Address - Country:US
Practice Address - Phone:973-742-6206
Practice Address - Fax:973-742-6206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty