Provider Demographics
NPI:1457767675
Name:D E RILEY MD LLC
Entity Type:Organization
Organization Name:D E RILEY MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-288-2220
Mailing Address - Street 1:4829 GALAXY PKWY
Mailing Address - Street 2:
Mailing Address - City:WARRENSVILLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44128-5900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4829 GALAXY PKWY
Practice Address - Street 2:
Practice Address - City:WARRENSVILLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44128-5900
Practice Address - Country:US
Practice Address - Phone:216-288-2220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0699721Medicaid