Provider Demographics
NPI:1528066578
Name:RIFFEY, ANDREW RAY (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:RAY
Last Name:RIFFEY
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:PO BOX 19639
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:844-470-2486
Practice Address - Street 1:374 E GRAND AVE # 6740
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3962
Practice Address - Country:US
Practice Address - Phone:618-453-3311
Practice Address - Fax:618-453-4449
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2024-05-10
Deactivation Date:2006-03-31
Deactivation Code:
Reactivation Date:2006-05-01
Provider Licenses
StateLicense IDTaxonomies
IL036-112145207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL717084OtherHEALTHLINK
IL614260006OtherMEDICARE PART B
ILI33595OtherTRICARE
IL036112145OtherIDPA FEE FOR SERVICE
ILI33595OtherBLUE CROSS BLUE SHIELD
IL080113710OtherUNITED HEALTHCARE RR MEDI
IL613392200OtherDOL FECA
IL036-112145Medicaid
IL108735OtherHEALTH ALLIANCE
ILI33595OtherTRICARE