Provider Demographics
NPI:1427165059
Name:RIVERVIEW HOSPITAL
Entity type:Organization
Organization Name:RIVERVIEW HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-664-5400
Mailing Address - Street 1:2237 ENGLE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46809-1404
Mailing Address - Country:US
Mailing Address - Phone:260-747-2353
Mailing Address - Fax:260-747-6368
Practice Address - Street 1:2237 ENGLE RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46809-1404
Practice Address - Country:US
Practice Address - Phone:260-747-2353
Practice Address - Fax:260-747-6368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100266110CMedicaid
IN100266110CMedicaid