Basic Information
| Provider Information | |||||||||
| NPI: | 1871682229 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIEDE | ||||||||
| FirstName: | KELLER | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 E CHESTNUT ST STE 303 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026295552 | ||||||||
| FaxNumber: | 5026293132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 07/21/2016 | ||||||||
| 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 | 207R00000X | 39447 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200804010 | 01 | IN | MEDICAID - IN - NIS | OTHER | 50020902 | 01 | KY | PASSPORT - NIS | OTHER | P00641377 | 01 | KY | RAILROAD KY MEDICARE - NIS | OTHER | 000000587061 | 01 | KY | ANTHEM - NIS | OTHER | 099184 | 01 | KY | SIHO - NIS | OTHER | 2545169 | 01 | KY | UNITED HEALTH CARE | OTHER | P00265558 | 01 | KY | MEDICARE RR | OTHER | 64117104 | 05 | KY | MEDICAID | 000000373509 | 01 | KY | ANTHEM | OTHER | 000023034O | 01 | KY | HUMANA - NIS | OTHER | 00533071 | 01 | KY | MEDICARE - NIS | OTHER | 2706323 | 01 | KY | CIGNA - NIS | OTHER | 3856218 | 01 | KY | AETNA HMO ONLY | OTHER | 64117104 | 01 | KY | MEDICAID - NIS | OTHER | 7804714 | 01 | KY | AETNA | OTHER | 50008029 | 01 | KY | PASSPORT KY | OTHER |