Basic Information
Provider Information | |||||||||
NPI: | 1801037163 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GEORGE | ||||||||
FirstName: | RONDA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RIVERA | ||||||||
OtherFirstName: | RONDA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2705 N LEBANON ST STE 305 | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | IN | ||||||||
PostalCode: | 460528622 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2605 N LEBANON ST | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | IN | ||||||||
PostalCode: | 460521476 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7654858000 | ||||||||
FaxNumber: | 7654858239 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/17/2009 | ||||||||
LastUpdateDate: | 04/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 28160100A | IN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 208M00000X | 28160100A | IN | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 0058886 | 05 | OH |   | MEDICAID | 201046470 | 05 | IN |   | MEDICAID |