1376934224 NPI number — RIVERDALE MEDICAL, P.C.

Table of content: (NPI 1376934224)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376934224 NPI number — RIVERDALE MEDICAL, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERDALE MEDICAL, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
RIVERDALE MEDICAL
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376934224
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 E PUTNAM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENWICH
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06830-5643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-554-8166
Provider Business Mailing Address Fax Number:
888-397-2148

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 RIVERDALE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT CHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10573-2737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-554-8166
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/13/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MURPHY
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
203-554-8166

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  246366 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RA0201X , with the licence number: 246366 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RB0002X , with the licence number: 246366 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)