=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649968116
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY LEE RILEY II MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2023
-----------------------------------------------------
Last Update Date | 04/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 1ST AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-6402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-263-5506
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 703 FOREST RD
-----------------------------------------------------
City | WEST HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06516-7932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-980-1724
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 13-3971298
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------