Provider Demographics
NPI:1144417999
Name:RILEY, THADDEUS BEAM (PA)
Entity Type:Individual
Prefix:MR
First Name:THADDEUS
Middle Name:BEAM
Last Name:RILEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:947 EASTERN PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1573
Mailing Address - Country:US
Mailing Address - Phone:502-361-8801
Mailing Address - Fax:502-361-8821
Practice Address - Street 1:947 EASTERN PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1573
Practice Address - Country:US
Practice Address - Phone:502-361-8801
Practice Address - Fax:502-361-8821
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1070363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1144417999OtherNPI
KY1144417999OtherNPI