Provider Demographics
NPI:1083865554
Name:RIVERTON PHYSICIAN PRACTICES LLC
Entity Type:Organization
Organization Name:RIVERTON PHYSICIAN PRACTICES LLC
Other - Org Name:WIND RIVER ONCOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:PO BOX 758
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83877-0758
Mailing Address - Country:US
Mailing Address - Phone:208-773-6400
Mailing Address - Fax:
Practice Address - Street 1:1035 ROSE LN
Practice Address - Street 2:SUITE D
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2286
Practice Address - Country:US
Practice Address - Phone:307-856-4688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty