Provider Demographics
NPI:1992292965
Name:DOWNRIVER, PC
Entity type:Organization
Organization Name:DOWNRIVER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:G
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-310-7334
Mailing Address - Street 1:DEPT. 880231 PO BOX 29650
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9650
Mailing Address - Country:US
Mailing Address - Phone:972-412-5299
Mailing Address - Fax:469-453-3374
Practice Address - Street 1:3906 EDGEVALE CT
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-7612
Practice Address - Country:US
Practice Address - Phone:972-412-5299
Practice Address - Fax:469-453-3374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-16
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Single Specialty