Provider Demographics
NPI:1053398370
Name:RIECKER, BRYAN A
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:A
Last Name:RIECKER
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 1:3559 NEWTON ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-1051
Mailing Address - Country:US
Mailing Address - Phone:812-482-4005
Mailing Address - Fax:812-482-9799
Practice Address - Street 1:3559 NEWTON ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-1051
Practice Address - Country:US
Practice Address - Phone:812-482-4005
Practice Address - Fax:812-482-9799
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001474A111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000284208OtherBLUE CROSS BLUE SHIELD
IN256100AMedicare PIN