Provider Demographics
NPI:1356331805
Name:RIEDEL, ROGER (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:RIEDEL
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 1:744 MIDDLE CREEK RD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37862-5019
Mailing Address - Country:US
Mailing Address - Phone:865-446-9575
Mailing Address - Fax:865-446-9576
Practice Address - Street 1:744 MIDDLE CREEK RD
Practice Address - Street 2:SUITE 114
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-5019
Practice Address - Country:US
Practice Address - Phone:865-446-9575
Practice Address - Fax:865-446-9576
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36883207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH71760Medicare UPIN
TN3878757Medicare PIN
TN3734041Medicare PIN