Provider Demographics
NPI:1376975045
Name:RILEY, ANDRAE G
Entity Type:Individual
Prefix:MR
First Name:ANDRAE
Middle Name:G
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 1:8721 AVENUE L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4716
Mailing Address - Country:US
Mailing Address - Phone:917-627-3060
Mailing Address - Fax:347-713-5278
Practice Address - Street 1:8721 AVENUE L
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-4716
Practice Address - Country:US
Practice Address - Phone:917-627-3060
Practice Address - Fax:347-713-5278
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies