Provider Demographics
NPI:1356490932
Name:RILEY, MARK L (DPM)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:L
Last Name:RILEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1327 PIERCE
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009
Mailing Address - Country:US
Mailing Address - Phone:313-561-5800
Mailing Address - Fax:
Practice Address - Street 1:1327 PIERCE STREET
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009
Practice Address - Country:US
Practice Address - Phone:313-561-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001479213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist