Basic Information
| Provider Information | |||||||||
| NPI: | 1922192574 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY MEDICAL CARE OF RIVERVIEW PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7229 US HIGHWAY 301 S | ||||||||
| Address2: | |||||||||
| City: | RIVERVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335784346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136778418 | ||||||||
| FaxNumber: | 8136778419 | ||||||||
| Practice Location | |||||||||
| Address1: | 7229 US HIGHWAY 301 S | ||||||||
| Address2: | |||||||||
| City: | RIVERVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335784346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136778418 | ||||||||
| FaxNumber: | 8136778419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 01/05/2010 | ||||||||
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| AuthorizedOfficialLastName: | LOUDERBACK | ||||||||
| AuthorizedOfficialFirstName: | EDDIE | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8136778418 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | C.M.M. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 263029000 | 05 | FL | MEDICAID |