Provider Demographics
NPI:1316191125
Name:RIVER VALLEY ORTHOPEDICS & SPORTS MEDICINE PC
Entity type:Organization
Organization Name:RIVER VALLEY ORTHOPEDICS & SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:574-674-6700
Mailing Address - Street 1:320 LINCOLN WAY E
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46561-2767
Mailing Address - Country:US
Mailing Address - Phone:574-674-6700
Mailing Address - Fax:574-674-7171
Practice Address - Street 1:320 LINCOLN WAY E
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:IN
Practice Address - Zip Code:46561-2767
Practice Address - Country:US
Practice Address - Phone:574-674-6700
Practice Address - Fax:574-674-7171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1242030001Medicare NSC