Provider Demographics
NPI:1326377920
Name:RIVERTON PHYSICIAN PRACTICES LLC
Entity type:Organization
Organization Name:RIVERTON PHYSICIAN PRACTICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JESS
Authorized Official - Middle Name:N
Authorized Official - Last Name:JUDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:2002 W SUNSET DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-2283
Mailing Address - Country:US
Mailing Address - Phone:307-857-5280
Mailing Address - Fax:307-857-5215
Practice Address - Street 1:2002 W SUNSET DR
Practice Address - Street 2:SUITE 2
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2283
Practice Address - Country:US
Practice Address - Phone:307-857-5280
Practice Address - Fax:307-857-5215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1518118017Medicaid
WY1518118017Medicaid