Basic Information
Provider Information | |||||||||
NPI: | 1558350926 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RIEKER | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | GARRETT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7219 N LITCHFIELD RD | ||||||||
Address2: | 56TH MEDICAL GROUP | ||||||||
City: | LUKE AFB | ||||||||
State: | AZ | ||||||||
PostalCode: | 853091529 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6238564396 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7219 N LITCHFIELD RD | ||||||||
Address2: | 56TH MEDICAL GROUP | ||||||||
City: | LUKE AFB | ||||||||
State: | AZ | ||||||||
PostalCode: | 853091529 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6238564396 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/18/2005 | ||||||||
LastUpdateDate: | 06/09/2016 | ||||||||
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 | 208000000X | 01054970A | IN | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 01054970A | 01 | IN | STATE MEDICAL LICENSE | OTHER |