Provider Demographics
NPI:1386638005
Name:RIELLY, JAMES
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:RIELLY
Suffix:
Gender:M
Credentials:
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 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:395 W COUGAR BLVD STE 503
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3323
Practice Address - Country:US
Practice Address - Phone:801-374-9100
Practice Address - Fax:801-374-9117
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY249582208600000X
PAMD4691032086S0129X
SC832192086S0129X
UT11889299-12052086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC832193Medicaid
GAF32215Medicare UPIN
GA02BBCMPMedicare ID - Type Unspecified