Provider Demographics
NPI:1124291596
Name:RIVER VALLEY ORTHOPEDICS, P.C.
Entity type:Organization
Organization Name:RIVER VALLEY ORTHOPEDICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-459-9404
Mailing Address - Street 1:350 LAFAYETTE AVE SE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4600
Mailing Address - Country:US
Mailing Address - Phone:616-456-8515
Mailing Address - Fax:
Practice Address - Street 1:350 LAFAYETTE AVE SE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4600
Practice Address - Country:US
Practice Address - Phone:616-456-8515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002014213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN87680001Medicare UPIN