Provider Demographics
NPI:1932354222
Name:SANDY RIVER FAMILY CARE INC
Entity type:Organization
Organization Name:SANDY RIVER FAMILY CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAJENDRA
Authorized Official - Middle Name:S
Authorized Official - Last Name:TRIVEDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-685-7095
Mailing Address - Street 1:309 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-2925
Mailing Address - Country:US
Mailing Address - Phone:434-797-4150
Mailing Address - Fax:434-797-1300
Practice Address - Street 1:4520 MEDICAL CENTER RD
Practice Address - Street 2:
Practice Address - City:AXTON
Practice Address - State:VA
Practice Address - Zip Code:24054-2822
Practice Address - Country:US
Practice Address - Phone:434-685-7095
Practice Address - Fax:434-797-1300
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL FAMILY CARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-01
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101053147207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACL9316OtherPALMETTO GBA MEDICARE
VA258015OtherANTHEM BC
VA005619505Medicaid
NC89063VUOtherMEDICAID NC
VACL9316OtherPALMETTO GBA MEDICARE
VA258015OtherANTHEM BC