Provider Demographics
NPI:1285661595
Name:RIVERSTONEMD PC
Entity type:Organization
Organization Name:RIVERSTONEMD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-258-4142
Mailing Address - Street 1:101 RIVERSTONE VIS
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-6648
Mailing Address - Country:US
Mailing Address - Phone:706-258-4100
Mailing Address - Fax:706-632-3585
Practice Address - Street 1:101 RIVERSTONE VIS
Practice Address - Street 2:SUITE 205
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-6648
Practice Address - Country:US
Practice Address - Phone:706-258-4100
Practice Address - Fax:706-632-3585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032826261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000621244AMedicaid
GA113858Medicare PIN