Provider Demographics
NPI:1871580589
Name:RILEY, RANDY H (PT)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:H
Last Name:RILEY
Suffix:
Gender:M
Credentials:PT
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 729
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-0729
Mailing Address - Country:US
Mailing Address - Phone:334-793-2663
Mailing Address - Fax:334-836-2247
Practice Address - Street 1:404 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2563
Practice Address - Country:US
Practice Address - Phone:334-308-9797
Practice Address - Fax:334-836-2247
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH3681225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL121690Medicaid
AL890011740Medicaid
AL511-09120OtherBCBS OF ALABAMA
AL515-21795OtherBCBS - EPR REHAB
AL515-21795OtherBCBS - EPR REHAB
ALP21090Medicare UPIN