Provider Demographics
NPI:1790189678
Name:RILEY, MAURIO
Entity Type:Individual
Prefix:
First Name:MAURIO
Middle Name:
Last Name:RILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PALMETTO HEALTH PKWY STE 104
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-1754
Mailing Address - Country:US
Mailing Address - Phone:803-782-4278
Mailing Address - Fax:
Practice Address - Street 1:100 PALMETTO HEALTH PKWY STE 104
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1754
Practice Address - Country:US
Practice Address - Phone:803-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2211363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant