Healthcare Provider Details

I. General information

NPI: 1407051634
Provider Name (Legal Business Name): NICOLE DAVIS RIORDAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N MICHIGAN ST
SOUTH BEND IN
46601-1033
US

IV. Provider business mailing address

615 N MICHIGAN ST
SOUTH BEND IN
46601-1033
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-7459
  • Fax: 574-647-3658
Mailing address:
  • Phone: 574-647-7167
  • Fax: 574-647-3671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01065523A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: