Provider Demographics
NPI:1396408290
Name:RIVER VALLEY MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:RIVER VALLEY MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RADHIKA
Authorized Official - Middle Name:N
Authorized Official - Last Name:KOLLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:563-271-3023
Mailing Address - Street 1:4626 PROGRESS DR STE C
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3485
Mailing Address - Country:US
Mailing Address - Phone:563-551-4200
Mailing Address - Fax:563-441-9101
Practice Address - Street 1:4626 PROGRESS DR STE C
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3485
Practice Address - Country:US
Practice Address - Phone:563-551-4200
Practice Address - Fax:563-441-9101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-18
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G81285OtherMEDICARE
IA1598744096Medicaid