Provider Demographics
NPI:1447581079
Name:RIVER PARK FAMILY MEDICINE, PC
Entity Type:Organization
Organization Name:RIVER PARK FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGALBO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:315-764-1447
Mailing Address - Street 1:908 NIAGARA FALLS BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-2019
Mailing Address - Country:US
Mailing Address - Phone:716-692-3302
Mailing Address - Fax:716-692-4342
Practice Address - Street 1:15 HOSPITAL DR
Practice Address - Street 2:SUITE B
Practice Address - City:MASSENA
Practice Address - State:NY
Practice Address - Zip Code:13662-1037
Practice Address - Country:US
Practice Address - Phone:315-764-1447
Practice Address - Fax:315-764-1447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188335207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02632048Medicaid
NYBA0417Medicare PIN