MEDICARE: BRADEN CRAGG RILEY D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	02000713	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000215219	OTHER	IN	BCBS

General Provider Information

NPI Number	:	1679516769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADEN CRAGG RILEY D.O.

Provider Business Mailing Address
First Line	:	707 E CEDAR ST
Second Line	:	STE 200
City	:	SOUTH BEND
State	:	IN
Zip	:	46617-2057
Country	:	US
Telephone Number	:	574-335-8700
Fax Number	:	574-335-0760

Provider Business Practice Location Address
First Line	:	12563 STATE ROAD 23
Second Line	:
City	:	GRANGER
State	:	IN
Zip	:	46530-9226
Country	:	US
Telephone Number	:	574-277-2090
Fax Number	:	574-277-2175

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	01/03/2020

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