Provider Demographics
NPI:1538144126
Name:WILEY, BRIAN (DO)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WILEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BREWSTER ST
Mailing Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-4400
Mailing Address - Country:US
Mailing Address - Phone:401-729-2191
Mailing Address - Fax:401-729-2517
Practice Address - Street 1:111 BREWSTER ST
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4400
Practice Address - Country:US
Practice Address - Phone:401-729-2191
Practice Address - Fax:401-729-2517
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDO00534207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007059107OtherMEDICARE PTAN
RI7009052Medicaid
RI7009052Medicaid