Provider Demographics
NPI:1104874031
Name:RILEY, THADDEUS H (MD)
Entity type:Individual
Prefix:
First Name:THADDEUS
Middle Name:H
Last Name:RILEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23702 HWY 80 E
Mailing Address - Street 2:PO BOX 957
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459
Mailing Address - Country:US
Mailing Address - Phone:912-489-4090
Mailing Address - Fax:912-765-5028
Practice Address - Street 1:23702 HWY 80 E
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458
Practice Address - Country:US
Practice Address - Phone:912-489-4090
Practice Address - Fax:912-765-5028
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028637207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00351601CMedicaid
GA08BDDNKMedicare ID - Type Unspecified
GA00351601CMedicaid