Healthcare Provider Details

I. General information

NPI: 1346720653
Provider Name (Legal Business Name): RILEY RICHARD GOODRICH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FODEN RD, EAST STE 203
SOUTH PORTLAND ME
04106-2327
US

IV. Provider business mailing address

100 GANNETT DR STE C
SOUTH PORTLAND ME
04106-5900
US

V. Phone/Fax

Practice location:
  • Phone: 207-874-1489
  • Fax: 207-523-8590
Mailing address:
  • Phone: 207-828-0361
  • Fax: 207-874-1483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAN1826
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: