Provider Demographics
NPI:1093882805
Name:RIVERSTONE IMAGING CENTER
Entity Type:Organization
Organization Name:RIVERSTONE IMAGING CENTER
Other - Org Name:RIVERSTONEMD, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:706-258-4133
Mailing Address - Street 1:101 RIVERSTONE VIS
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-6648
Mailing Address - Country:US
Mailing Address - Phone:706-258-4120
Mailing Address - Fax:
Practice Address - Street 1:101 RIVERSTONE VIS
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-6648
Practice Address - Country:US
Practice Address - Phone:706-258-4120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANOT REQUIRED261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA085001714GMedicaid
GA085001714GMedicaid