Basic Information
| Provider Information | |||||||||
| NPI: | 1669956025 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVER VALLEY ORTHOPEDICS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 LEFFINGWELL AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495256406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164597101 | ||||||||
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| Practice Location | |||||||||
| Address1: | 350 LAFAYETTE AVE SE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164568515 | ||||||||
| FaxNumber: | 6164568208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2018 | ||||||||
| LastUpdateDate: | 03/14/2019 | ||||||||
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| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | JOEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6164597101 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RIVER VALLEY ORTHOPEDICS, P.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | OM51600 | 01 | MI | MEDICARE | OTHER |