Provider Demographics
NPI:1366930943
Name:RILEY, SAMUEL (DO)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:RILEY
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 1:3400 WAKE FOREST ROAD
Mailing Address - Street 2:INPATIENT MEDICINE 4TH FLOOR
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609
Mailing Address - Country:US
Mailing Address - Phone:724-612-5487
Mailing Address - Fax:
Practice Address - Street 1:2310 ERWIN RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710
Practice Address - Country:US
Practice Address - Phone:724-612-5487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-29
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2021-01242207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2021-01242OtherNORTH CAROLINA MEDICAL BOARD