Provider Demographics
NPI:1669935631
Name:GROGAN, RILEY SEAN (MD)
Entity type:Individual
Prefix:
First Name:RILEY
Middle Name:SEAN
Last Name:GROGAN
Suffix:
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 1:169 ASHLEY AVE RM 202
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-8905
Mailing Address - Country:US
Mailing Address - Phone:406-871-3770
Mailing Address - Fax:
Practice Address - Street 1:169 ASHLEY AVE RM 202
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-5429
Practice Address - Country:US
Practice Address - Phone:406-871-3770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI74548-20208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program