Provider Demographics
NPI:1063793396
Name:RILEY, CAMERON W (PT)
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:W
Last Name:RILEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 CENTER ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36604-1512
Mailing Address - Country:US
Mailing Address - Phone:251-415-1670
Mailing Address - Fax:251-415-1671
Practice Address - Street 1:1610 CENTER ST
Practice Address - Street 2:SUITE B
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-1512
Practice Address - Country:US
Practice Address - Phone:251-415-1670
Practice Address - Fax:251-415-1671
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4877225100000X
ALPTH6763225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015077Medicaid
MS1033218524OtherGROUP NPI
MS09015077Medicaid