Provider Demographics
NPI:1417270158
Name:RILEY, CHRISTY L (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:L
Last Name:RILEY
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 1:980 W IRONWOOD DR
Mailing Address - Street 2:SUITE 302
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2668
Mailing Address - Country:US
Mailing Address - Phone:208-292-5437
Mailing Address - Fax:208-292-5441
Practice Address - Street 1:980 W IRONWOOD DR
Practice Address - Street 2:SUITE 302
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2668
Practice Address - Country:US
Practice Address - Phone:208-292-5437
Practice Address - Fax:208-292-5437
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-09
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA115031208000000X
CA390200000X
IDM-12160208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGV115ZMedicare PIN
CARES000Medicare UPIN