Basic Information
| Provider Information | |||||||||
| NPI: | 1255623732 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RILEY | ||||||||
| FirstName: | JARRETT | ||||||||
| MiddleName: | EDWARD STEWART | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20325 N 51ST AVE STE 170 BLDG 9 | ||||||||
| Address2: | SUITE #170 BLDG 9 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232494928 | ||||||||
| FaxNumber: | 6232494971 | ||||||||
| Practice Location | |||||||||
| Address1: | 20325 N 51ST AVE | ||||||||
| Address2: | SUITE #170 BLDG 9 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853084624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232494928 | ||||||||
| FaxNumber: | 6232494971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2011 | ||||||||
| LastUpdateDate: | 02/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | O-0862 | ID | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | OP60536051 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 008756 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.