Provider Demographics
NPI:1043284391
Name:RILEY, PHILLIP J (DPM)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:J
Last Name:RILEY
Suffix:
Gender:
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 632476
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2476
Mailing Address - Country:US
Mailing Address - Phone:423-434-6410
Mailing Address - Fax:423-232-8576
Practice Address - Street 1:301 MED TECH PKWY STE 106
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2631
Practice Address - Country:US
Practice Address - Phone:423-434-6410
Practice Address - Fax:423-232-8576
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD653213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3354203Medicare ID - Type Unspecified
U91457Medicare UPIN