Provider Demographics
NPI:1851566020
Name:RILEY, MICHAEL BEN ANDREW (LSA, CSA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:BEN ANDREW
Last Name:RILEY
Suffix:
Gender:M
Credentials:LSA, CSA
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 11807
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77391-1807
Mailing Address - Country:US
Mailing Address - Phone:713-992-1086
Mailing Address - Fax:
Practice Address - Street 1:8215 LICHEN LN
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-4517
Practice Address - Country:US
Practice Address - Phone:832-559-3870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00319363AS0400X, 246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0027SXOtherBLUE CROSS BLUE SHIELD