MEDICARE: MR. JOSEPH RILEY CERTIFIED SURGICAL

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	246ZS0410X	Surgical Technologist

General Provider Information

NPI Number	:	1811187222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSEPH RILEY CERTIFIED SURGICAL

Provider Business Mailing Address
First Line	:	8111 WINDERSGATE CIR
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-1209
Country	:	US
Telephone Number	:	662-216-0563
Fax Number	:

Provider Business Practice Location Address
First Line	:	8111 WINDERSGATE CIR
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-1209
Country	:	US
Telephone Number	:	662-216-0563
Fax Number	:

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

Provider Enumeration Date	:	08/01/2007
Last Update Date	:	08/01/2007

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