Provider Demographics
NPI:1235202540
Name:RILEY, ELIZABETH C (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:C
Last Name:RILEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3229
Mailing Address - Country:US
Mailing Address - Phone:502-562-4358
Mailing Address - Fax:502-562-6811
Practice Address - Street 1:529 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3229
Practice Address - Country:US
Practice Address - Phone:502-562-4358
Practice Address - Fax:502-562-6811
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA220429207RH0003X
KY43332207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50027776OtherPASSPORT HEALTH PLAN
KY7100113260Medicaid
KY50027776OtherPASSPORT HEALTH PLAN