Provider Demographics
NPI:1720056385
Name:RIEGER, MARK DAVID (ATC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:RIEGER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 MAPLE TREE LN
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-3537
Mailing Address - Country:US
Mailing Address - Phone:217-586-3772
Mailing Address - Fax:
Practice Address - Street 1:810 W ANTHONY DR
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802-7431
Practice Address - Country:US
Practice Address - Phone:217-383-6992
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer