Basic Information
Provider Information | |||||||||
NPI: | 1881642809 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RIVER PARK HOSPITAL LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RIVER PARK HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1559 SPARTA ST | ||||||||
Address2: |   | ||||||||
City: | MC MINNVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 371101316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9318154000 | ||||||||
FaxNumber: | 9318154710 | ||||||||
Practice Location | |||||||||
Address1: | 1559 SPARTA ST | ||||||||
Address2: |   | ||||||||
City: | MC MINNVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 371101316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9318154000 | ||||||||
FaxNumber: | 9318154710 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2006 | ||||||||
LastUpdateDate: | 02/19/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COFFEY | ||||||||
AuthorizedOfficialFirstName: | SHELTON | ||||||||
AuthorizedOfficialMiddleName: | RAY | ||||||||
AuthorizedOfficialTitleorPosition: | VP REIMBURSEMENT | ||||||||
AuthorizedOfficialTelephone: | 6157643009 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0000002909 | TN | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | RIV015N | 05 | AL |   | MEDICAID | 1000162 | 05 | TN |   | MEDICAID |