Provider Demographics
NPI:1437264942
Name:RILEY, SUZANNE M (MD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:M
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:PO BOX 2290
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54221-2290
Mailing Address - Country:US
Mailing Address - Phone:920-320-2591
Mailing Address - Fax:
Practice Address - Street 1:2300 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-3712
Practice Address - Country:US
Practice Address - Phone:920-320-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12189246Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Q00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31810700Medicaid
WI220027739OtherMEDICARE RAILROAD
WI31810700Medicaid
WI003800205Medicare ID - Type Unspecified