Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 08001474A | IN |
NPI | 1053398370 |
---|---|
Provider Name | Dr. Bryan A Riecker |
First Address | Jasper, IN 47546-1051 |
Second Address | Jasper, IN 47546-1051 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/12/2005 |
Last Update Date | 22/04/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000284208 | BLUE CROSS BLUE SHIELD (01) | IN |