Healthcare Provider Details

I. General information

NPI: 1932881117
Provider Name (Legal Business Name): MR. RILEY GORDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 08/07/2023
Certification Date: 08/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N MERIDIAN ST STE 906
INDIANAPOLIS IN
46204-1727
US

IV. Provider business mailing address

320 N MERIDIAN ST STE 906
INDIANAPOLIS IN
46204-1727
US

V. Phone/Fax

Practice location:
  • Phone: 317-759-4262
  • Fax: 317-426-2925
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246Q00000X
TaxonomyPathology Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: