Provider Demographics
NPI:1902856719
Name:RILEY, EDWARD CLARK III (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:CLARK
Last Name:RILEY
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 NORTH 30TH STREET
Mailing Address - Street 2:IVINSON MEMORIAL HOSPITAL
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072
Mailing Address - Country:US
Mailing Address - Phone:307-742-2141
Mailing Address - Fax:307-742-9419
Practice Address - Street 1:255 NORTH 30TH STREET
Practice Address - Street 2:IVINSON MEMORIAL HOSPITAL
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072
Practice Address - Country:US
Practice Address - Phone:307-742-2141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO624207Q00000X
WY7932A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51045390OtherBLUE CROSS BLUE SHIELD
AL009917200Medicaid
080155685OtherRAILROAD
H04004Medicare UPIN
AL009917200Medicaid
510I930010Medicare UPIN
510I930010Medicare PIN