Basic Information
| Provider Information | |||||||||
| NPI: | 1497753776 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH RIVER FAMILY HEALTH CENTER PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 606 4TH AVE W | ||||||||
| Address2: | |||||||||
| City: | PALMETTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342215226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417227785 | ||||||||
| FaxNumber: | 9417295267 | ||||||||
| Practice Location | |||||||||
| Address1: | 606 4TH AVE W | ||||||||
| Address2: | |||||||||
| City: | PALMETTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342215226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417227785 | ||||||||
| FaxNumber: | 9417295267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | RAITZ | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9417227785 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 052613400 | 05 | FL | MEDICAID | 68130 | 01 | FL | AETNA | OTHER | 77066 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |