Provider Demographics
NPI:1063475788
Name:RIVER VALLEY PEDIATRICS, PC
Entity Type:Organization
Organization Name:RIVER VALLEY PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:T
Authorized Official - Last Name:DUBE'
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-276-2222
Mailing Address - Street 1:1335 PHAY AVE
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-2349
Mailing Address - Country:US
Mailing Address - Phone:719-276-2222
Mailing Address - Fax:719-276-9199
Practice Address - Street 1:1335 PHAY AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2334
Practice Address - Country:US
Practice Address - Phone:719-276-2222
Practice Address - Fax:719-276-9199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO93233086Medicaid
CO803615Medicare ID - Type Unspecified