Provider Demographics
NPI:1093950560
Name:GRANT/RIVERSIDE MEDICAL CARE FOUNDATION, INC
Entity Type:Organization
Organization Name:GRANT/RIVERSIDE MEDICAL CARE FOUNDATION, INC
Other - Org Name:MAX SPORTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALITS
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HEDGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-544-6356
Mailing Address - Street 1:5350 FRANTZ RD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3705 OLENTANGY RIVER RD
Practice Address - Street 2:STE 260
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3467
Practice Address - Country:US
Practice Address - Phone:614-586-1220
Practice Address - Fax:614-586-1237
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRANT/RIVERSIDE MEDICAL CARE FOUNDATION, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicaid
OHPENDINGMedicare PIN