1447581079 NPI number — RIVER PARK FAMILY MEDICINE, PC

Table of content: (NPI 1447581079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447581079 NPI number — RIVER PARK FAMILY MEDICINE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVER PARK FAMILY MEDICINE, PC
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:
1447581079
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
908 NIAGARA FALLS BLVD
Provider Second Line Business Mailing Address:
SUITE 208
Provider Business Mailing Address City Name:
NORTH TONAWANDA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14120-2019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-692-3302
Provider Business Mailing Address Fax Number:
716-692-4342

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MASSENA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13662-1037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-764-1447
Provider Business Practice Location Address Fax Number:
315-764-1447
Provider Enumeration Date:
01/21/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LOGALBO
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
Authorized Official Title or Position:
DO/OWNER
Authorized Official Telephone Number:
315-764-1447

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  188335 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02632048 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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