Provider Demographics
NPI:1558681817
Name:RILEY, THOMAS DALEY IV (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:DALEY
Last Name:RILEY
Suffix:IV
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 1:650 NE 32ND ST UNIT 3003
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-5260
Mailing Address - Country:US
Mailing Address - Phone:786-845-6645
Mailing Address - Fax:215-330-0408
Practice Address - Street 1:7000 SW 62ND AVE STE 330
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4717
Practice Address - Country:US
Practice Address - Phone:786-238-7402
Practice Address - Fax:215-330-0408
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-09
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME124360207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1178622500Medicaid