=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316111768
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER J. RILEY MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2008
-----------------------------------------------------
Last Update Date | 11/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5700 BOTTINEAU BLVD SUITE 100
-----------------------------------------------------
City | CRYSTAL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55429-3183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-504-6500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5700 BOTTINEAU BLVD SUITE 100
-----------------------------------------------------
City | CRYSTAL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55429-3183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-504-6500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 50322
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------