Provider Demographics
NPI:1366675100
Name:RILEY, MALINDA K (MPT)
Entity Type:Individual
Prefix:
First Name:MALINDA
Middle Name:K
Last Name:RILEY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5629
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47716-5629
Mailing Address - Country:US
Mailing Address - Phone:812-759-7451
Mailing Address - Fax:812-759-7482
Practice Address - Street 1:415 CROSSLAKE DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-8263
Practice Address - Country:US
Practice Address - Phone:812-476-0409
Practice Address - Fax:812-476-1016
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008665A225100000X
KY005971225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000714667OtherBLUE CROSS BLUE SHIELD
KY000000808883OtherBLUE CROSS BLUE SHIELD
IN000000725882OtherBLUE CROSS BLUE SHIELD
IN201020130Medicaid
INM400048478Medicare PIN
IN000000714667OtherBLUE CROSS BLUE SHIELD
INM400048480Medicare PIN
KY000000808883OtherBLUE CROSS BLUE SHIELD