Provider Demographics
NPI:1417506213
Name:JESSE RILEY DPM PC
Entity Type:Organization
Organization Name:JESSE RILEY DPM PC
Other - Org Name:SUMMIT FOOT AND ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:ELLSWORTH
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-218-3338
Mailing Address - Street 1:41 N 400 W STE A
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-2021
Mailing Address - Country:US
Mailing Address - Phone:801-218-3338
Mailing Address - Fax:801-658-5351
Practice Address - Street 1:41 N 400 W STE A
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-2021
Practice Address - Country:US
Practice Address - Phone:801-218-3338
Practice Address - Fax:801-658-5351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT9037769-0501OtherLICENSE
UTFR4555922OtherDEA