Provider Demographics
NPI:1558355032
Name:RILEY, RANDALL R (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:R
Last Name:RILEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 W 86TH STREET
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3700 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0541
Practice Address - Country:US
Practice Address - Phone:317-872-6287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044173A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000765918OtherANTHEM PROVIDER NUMBER
IN200472380Medicaid
INP01126758Medicare PIN
INM400072482Medicare PIN
IN000000765918OtherANTHEM PROVIDER NUMBER
ING52959Medicare UPIN
IN160560Medicare ID - Type Unspecified