=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275791832
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RILEY A SMYTH M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2008
-----------------------------------------------------
Last Update Date | 03/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1789 SHAWANO AVE
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54303-3243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-499-2766
-----------------------------------------------------
Fax | 920-499-7080
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1789 SHAWANO AVE
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54303-3243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-499-2766
-----------------------------------------------------
Fax | 920-499-7080
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 4301116329
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 62709
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------