Basic Information
| Provider Information | |||||||||
| NPI: | 1528066578 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIFFEY | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | RAY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 513 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ANNA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629061668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6188334471 | ||||||||
| FaxNumber: | 6188338878 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 N 1ST ST | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629951544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186582811 | ||||||||
| FaxNumber: | 6186582439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 07/05/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/31/2006 | ||||||||
| NPIReactivationDate: | 05/01/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036-112145 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080113710 | 01 | IL | UNITED HEALTHCARE RR MEDI | OTHER | I33595 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 036-112145 | 05 | IL | MEDICAID | 108735 | 01 | IL | HEALTH ALLIANCE | OTHER | 614260006 | 01 | IL | MEDICARE PART B | OTHER | 613392200 | 01 | IL | DOL FECA | OTHER | 036112145 | 01 | IL | IDPA FEE FOR SERVICE | OTHER | 717084 | 01 | IL | HEALTHLINK | OTHER | I33595 | 01 | IL | TRICARE | OTHER |