Basic Information
| Provider Information | |||||||||
| NPI: | 1508432816 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIYA | ||||||||
| FirstName: | UNKNOWN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3249 SOUTH PARK AVE LOYOLA MEDICINE MACNEAL HOSPITAL | ||||||||
| Address2: | |||||||||
| City: | BERWYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087833401 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3722 SOUTH HARLEM MACNEAL CENTER FOR INTERNAL MEDICINE | ||||||||
| Address2: | SUITE LL34 | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087836566 | ||||||||
| FaxNumber: | 7087836567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2021 | ||||||||
| LastUpdateDate: | 09/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125-078985 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.