Provider Demographics
NPI:1407051634
Name:RIORDAN, NICOLE DAVIS (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DAVIS
Last Name:RIORDAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1033
Mailing Address - Country:US
Mailing Address - Phone:574-647-7167
Mailing Address - Fax:574-647-3671
Practice Address - Street 1:615 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1033
Practice Address - Country:US
Practice Address - Phone:574-647-7459
Practice Address - Fax:574-647-3658
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065523A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00891626/CDOtherRR MEDICARE
IN000000655105OtherANTHEM
IN200981060Medicaid
IN200981060Medicaid