Provider Demographics
NPI:1275687113
Name:RIVER VALLEY FAMILY PRACTICE LTD
Entity Type:Organization
Organization Name:RIVER VALLEY FAMILY PRACTICE LTD
Other - Org Name:DAVID GANNON, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-739-4223
Mailing Address - Street 1:602 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6145
Mailing Address - Country:US
Mailing Address - Phone:309-736-4173
Mailing Address - Fax:309-797-5653
Practice Address - Street 1:2550 24TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5304
Practice Address - Country:US
Practice Address - Phone:309-793-4223
Practice Address - Fax:309-793-6276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360532801Medicaid
IL8132003OtherBLUE SHIELD
ILC43714Medicare UPIN
IL0360532801Medicaid