Provider Demographics
NPI:1275791832
Name:SMYTH, RILEY A (MD)
Entity Type:Individual
Prefix:DR
First Name:RILEY
Middle Name:A
Last Name:SMYTH
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 1:1789 SHAWANO AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-3243
Mailing Address - Country:US
Mailing Address - Phone:920-499-2766
Mailing Address - Fax:920-499-7080
Practice Address - Street 1:1789 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3243
Practice Address - Country:US
Practice Address - Phone:920-499-2766
Practice Address - Fax:920-499-7080
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43011163292085R0202X
WI627092085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI62709-20OtherWI LICENSE
ABROtherAMERICAN BOARD OF RADIOLOGY/DIAGNOSTIC RADIOLOGY
MI4301116329OtherMI LICCENSE