1790042158 NPI number — RIVER RIDGE PEDIATRICS, P.A.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790042158 NPI number — RIVER RIDGE PEDIATRICS, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVER RIDGE PEDIATRICS, P.A.
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:
Provider Other Organization Name Type Code:
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:
1790042158
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1526 LEANDER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GEORGETOWN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78628-8801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-930-1309
Provider Business Mailing Address Fax Number:
512-863-5222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1526 LEANDER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78628-8801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-930-1309
Provider Business Practice Location Address Fax Number:
512-863-5222
Provider Enumeration Date:
04/23/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GIPSON
Authorized Official First Name:
ADANA
Authorized Official Middle Name:
MILLIKEN
Authorized Official Title or Position:
PRESIDENT/MEDICAL DIRECTOR
Authorized Official Telephone Number:
512-930-1309

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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