Healthcare Provider Details

I. General information

NPI: 1609983766
Provider Name (Legal Business Name): KEITH B. RILEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 SE SUNNYSIDE RD.
CLACKAMAS OR
97015-8970
US

IV. Provider business mailing address

990 SE SUNNYSIDE RD
CLACKAMAS OR
97015-6910
US

V. Phone/Fax

Practice location:
  • Phone: 503-652-2880
  • Fax:
Mailing address:
  • Phone: 503-571-5649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD15711
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD00034279
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: