Provider Demographics
NPI:1093823536
Name:RIVER CITY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:RIVER CITY MEDICAL GROUP, INC.
Other - Org Name:SACRAMENTO FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:KENDRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:QUE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:916-228-4300
Mailing Address - Street 1:PO BOX 15470
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95851-0470
Mailing Address - Country:US
Mailing Address - Phone:916-228-4300
Mailing Address - Fax:916-382-4202
Practice Address - Street 1:4241 FLORIN RD
Practice Address - Street 2:SUITE 40
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2535
Practice Address - Country:US
Practice Address - Phone:916-391-2229
Practice Address - Fax:916-391-2291
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVER CITY MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-25
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86947207Q00000X
CA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0053750Medicaid
CAGR0053750Medicaid
CAGR0053750Medicaid
CAGR0053753Medicaid