Basic Information
Provider Information | |||||||||
NPI: | 1104845981 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RILEY | ||||||||
FirstName: | CHARLES | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 311 9TH ST N STE 310 | ||||||||
Address2: |   | ||||||||
City: | NAPLES | ||||||||
State: | FL | ||||||||
PostalCode: | 341025889 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2396248250 | ||||||||
FaxNumber: | 2396248251 | ||||||||
Practice Location | |||||||||
Address1: | 311 9TH ST N STE 310 | ||||||||
Address2: |   | ||||||||
City: | NAPLES | ||||||||
State: | FL | ||||||||
PostalCode: | 341025889 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2396248250 | ||||||||
FaxNumber: | 2396248251 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2006 | ||||||||
LastUpdateDate: | 11/07/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | ME131211 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | ME131211 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 022056000 | 05 | FL |   | MEDICAID | JC606Z | 01 | FL | MEDICARE | OTHER | 132051 | 05 | AZ |   | MEDICAID | IOWCJ | 01 | FL | BCBS | OTHER |