MEDICARE: TRACY M. RIORDAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	2002013047	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124094362
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY M. RIORDAN M.D.

Provider Business Mailing Address
First Line	:	1254 MAIN STREET
Second Line	:
City	:	IMPERIAL
State	:	MO
Zip	:	63052
Country	:	US
Telephone Number	:	636-741-3130
Fax Number	:

Provider Business Practice Location Address
First Line	:	1254 MAIN ST
Second Line	:
City	:	IMPERIAL
State	:	MO
Zip	:	63052-3861
Country	:	US
Telephone Number	:	636-741-3130
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2006
Last Update Date	:	09/20/2017

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