Provider Demographics
NPI:1104803519
Name:RILEY, KATHLEEN A (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:A
Last Name:RILEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 S FAYETTEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-6667
Mailing Address - Country:US
Mailing Address - Phone:336-625-2467
Mailing Address - Fax:336-625-2256
Practice Address - Street 1:713 S FAYETTEVILLE ST
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-6667
Practice Address - Country:US
Practice Address - Phone:336-625-2467
Practice Address - Fax:336-625-2256
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35734208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8971404Medicaid
NC8971404Medicaid