Healthcare Provider Details

I. General information

NPI: 1932295201
Provider Name (Legal Business Name): BRYAN J RILEY PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10590 N MERIDIAN ST # 105
CARMEL IN
46290
US

IV. Provider business mailing address

7517 WIND RIVER DR
SYLVANIA OH
43560-4319
US

V. Phone/Fax

Practice location:
  • Phone: 317-583-7800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50.001875RX
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50001875
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10004702A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: