Provider Demographics
NPI:1144216847
Name:RIVER PARK ASC LLC
Entity Type:Organization
Organization Name:RIVER PARK ASC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARCI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGRAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-336-2225
Mailing Address - Street 1:107 FRONT ST
Mailing Address - Street 2:STE.1100
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-2836
Mailing Address - Country:US
Mailing Address - Phone:318-336-2218
Mailing Address - Fax:
Practice Address - Street 1:107 FRONT ST
Practice Address - Street 2:STE.1100
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-2836
Practice Address - Country:US
Practice Address - Phone:318-336-2218
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA128261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03027576Medicaid
LA190020258ZOtherBLUE CROSS PROVIDER NUMBE
LA1464015Medicaid
LA190020258ZOtherBLUE CROSS PROVIDER NUMBE
LA190020258ZOtherBLUE CROSS PROVIDER NUMBE