Basic Information
| Provider Information | |||||||||
| NPI: | 1417915299 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVER PARK HOSPITAL LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RIVER PARK HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1559 SPARTA ST | ||||||||
| Address2: | |||||||||
| City: | MC MINNVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371101316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9318154000 | ||||||||
| FaxNumber: | 9318154710 | ||||||||
| Practice Location | |||||||||
| Address1: | 1559 SPARTA ST | ||||||||
| Address2: | |||||||||
| City: | MC MINNVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371101316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9318154000 | ||||||||
| FaxNumber: | 9318154710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 02/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | COFFEY | ||||||||
| AuthorizedOfficialFirstName: | SHELTON | ||||||||
| AuthorizedOfficialMiddleName: | RAY | ||||||||
| AuthorizedOfficialTitleorPosition: | VP REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 6157643009 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RIVER PARK HOSPITAL LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 0000002909 | TN | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | RIV015N | 05 | AL | MEDICAID | 1000162 | 05 | TN | MEDICAID | 044T151 | 05 | TN | MEDICAID |