Basic Information
| Provider Information | |||||||||
| NPI: | 1629057070 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RILEY | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 622 W 168TH ST | ||||||||
| Address2: | PH 1-137 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123052995 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 622 W 168TH ST | ||||||||
| Address2: | PH 1-137 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123052995 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 09/10/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 218288-1 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1525Q1 | 01 | NY | BLUECROSS BLUESHIELD | OTHER | 02091436 | 05 | NY | MEDICAID |