Healthcare Provider Details

I. General information

NPI: 1649245838
Provider Name (Legal Business Name): DAVID A RILEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 05/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 ANNE ST NW
BEMIDJI MN
56601-5103
US

IV. Provider business mailing address

PO BOX 2010
FARGO ND
58122-2484
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD00030575
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberMD00030575
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberMD00030575
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberMD00030575
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD00030575
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberMD00030575
License Number StateWA
# 7
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberMD00030575
License Number StateWA
# 8
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number59006
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: