Provider Demographics
NPI:1316585615
Name:RILEY, BRENDAN WILLIAM
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:WILLIAM
Last Name:RILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 PARK ST APT 30
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-3355
Mailing Address - Country:US
Mailing Address - Phone:508-916-0520
Mailing Address - Fax:
Practice Address - Street 1:372 PARK ST APT 30
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-3355
Practice Address - Country:US
Practice Address - Phone:508-916-0520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program