Basic Information
Provider Information | |||||||||
NPI: | 1770617664 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RIVERDALE FAMILY MEDICINE, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 760 | ||||||||
Address2: |   | ||||||||
City: | SMITHFIELD | ||||||||
State: | NC | ||||||||
PostalCode: | 275770760 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9199676646 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 127 E MARKET ST | ||||||||
Address2: |   | ||||||||
City: | SMITHFIELD | ||||||||
State: | NC | ||||||||
PostalCode: | 275773915 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9199676646 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/15/2007 | ||||||||
LastUpdateDate: | 08/07/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ZALDIVAR | ||||||||
AuthorizedOfficialFirstName: | MARIE | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9199676646 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 9801124 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 8911623 | 05 | NC |   | MEDICAID | 11623 | 01 | NC | BCNC | OTHER |