Provider Demographics
NPI:1609076629
Name:RILEY, J TIMOTHY (M D)
Entity type:Individual
Prefix:
First Name:J
Middle Name:TIMOTHY
Last Name:RILEY
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 UNION AVE.
Mailing Address - Street 2:STE 1005
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2761
Mailing Address - Country:US
Mailing Address - Phone:315-424-0253
Mailing Address - Fax:
Practice Address - Street 1:104 UNION AVE.
Practice Address - Street 2:STE 1005
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2761
Practice Address - Country:US
Practice Address - Phone:315-424-0253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2451752086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery