Provider Demographics
NPI:1083678098
Name:RIVERGATE SPORTS MEDICINE AND ORTHOPAEDIC SURGERY, P.C.
Entity Type:Organization
Organization Name:RIVERGATE SPORTS MEDICINE AND ORTHOPAEDIC SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:LANDSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-264-4785
Mailing Address - Street 1:353 NEW SHACKLE ISLAND RD
Mailing Address - Street 2:SUITE 110A
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-2379
Mailing Address - Country:US
Mailing Address - Phone:615-264-4785
Mailing Address - Fax:615-264-4786
Practice Address - Street 1:353 NEW SHACKLE ISLAND RD
Practice Address - Street 2:SUITE 110A
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2379
Practice Address - Country:US
Practice Address - Phone:615-264-4785
Practice Address - Fax:615-264-4786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-14
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000025005174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3080193Medicaid
TN3080193Medicare PIN
TN3080193Medicaid