MEDICARE: JAMES RIELLY

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	208600000X	Surgery Physician	249582	NY
2	2086S0129X	Vascular Surgery Physician	MD469103	PA
3	2086S0129X	Vascular Surgery Physician	83219	SC
4	2086S0129X	Vascular Surgery Physician	11889299-1205	UT

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	:	1386638005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES RIELLY

Provider Business Mailing Address
First Line	:	PO BOX 27128
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84127-0128
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	395 W COUGAR BLVD STE 503
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604-3323
Country	:	US
Telephone Number	:	801-374-9100
Fax Number	:	801-374-9117

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

Provider Enumeration Date	:	09/08/2005
Last Update Date	:	03/14/2024

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