Basic Information
| Provider Information | |||||||||
| NPI: | 1790987725 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVER CITY ALLERGY & MEDICAL PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 S MAIN ST STE 1300 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381035513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669490108 | ||||||||
| FaxNumber: | 2565479755 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 20TH ST N STE 2200 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352033261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669490108 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2007 | ||||||||
| LastUpdateDate: | 08/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2565474971 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207Y00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 000000740 | 01 | AL | PTAN | OTHER | 040015339 | 01 | GA | RAILROAD RETIREMENT MEDIC | OTHER | 051000740 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER |