Provider Demographics
NPI:1033496070
Name:RIVERDALE MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:RIVERDALE MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MORELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-543-6949
Mailing Address - Street 1:189 MEDICAL WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-4905
Mailing Address - Country:US
Mailing Address - Phone:770-907-2333
Mailing Address - Fax:770-907-2299
Practice Address - Street 1:189 MEDICAL WAY
Practice Address - Street 2:SUITE B
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-4905
Practice Address - Country:US
Practice Address - Phone:770-907-2333
Practice Address - Fax:770-907-2299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2081P2900X, 208D00000X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty