Healthcare Provider Details

I. General information

NPI: 1669992418
Provider Name (Legal Business Name): WILLIAM A RIECK JR. DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 MEDICAL DR
GREENVILLE NC
27834-7503
US

IV. Provider business mailing address

PO BOX 751069
CHARLOTTE NC
28275-1069
US

V. Phone/Fax

Practice location:
  • Phone: 252-744-6683
  • Fax: 252-744-9617
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOT017879
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberOT017879
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberOT17879
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2022-01128
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: