Basic Information
| Provider Information | |||||||||
| NPI: | 1467648170 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERGATE DERMATOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 BLUEBIRD DR | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370722301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158597546 | ||||||||
| FaxNumber: | 6158517760 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 BLUEBIRD DR | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370722301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158597546 | ||||||||
| FaxNumber: | 6158517760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2007 | ||||||||
| LastUpdateDate: | 09/18/2007 | ||||||||
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| AuthorizedOfficialLastName: | LOVEN | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/LEAD DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 6158597546 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MDO17949 | TN | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1235116518 | 01 | TN | NPI # | OTHER | 3708943 | 01 | TN | MEDICARE GROUP # | OTHER |