Basic Information
| Provider Information | |||||||||
| NPI: | 1124291596 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVER VALLEY ORTHOPEDICS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 LAFAYETTE AVE SE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164568515 | ||||||||
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| Practice Location | |||||||||
| Address1: | 350 LAFAYETTE AVE SE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164568515 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2008 | ||||||||
| LastUpdateDate: | 04/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | BOB | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6164599404 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 5901002014 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.