Provider Demographics
NPI:1164440301
Name:RILEY, JOEL (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:RILEY
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:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6400 CLAYTON RD
Practice Address - Street 2:SUITE 216
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1850
Practice Address - Country:US
Practice Address - Phone:314-951-5368
Practice Address - Fax:314-951-5238
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR7G19207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202754933Medicaid
MO003013404Medicare PIN
E35269Medicare UPIN
MO202754933Medicaid