Provider Demographics
NPI:1366503955
Name:RILEY, JOHN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:RILEY
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 1:300 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:OROFINO
Mailing Address - State:ID
Mailing Address - Zip Code:83544-9034
Mailing Address - Country:US
Mailing Address - Phone:208-476-4511
Mailing Address - Fax:208-476-7898
Practice Address - Street 1:300 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:OROFINO
Practice Address - State:ID
Practice Address - Zip Code:83544-9034
Practice Address - Country:US
Practice Address - Phone:208-476-4511
Practice Address - Fax:208-476-7898
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-4996207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC36948Medicare UPIN