Provider Demographics
NPI:1467648170
Name:RIVERGATE DERMATOLOGY
Entity Type:Organization
Organization Name:RIVERGATE DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LEAD DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:H
Authorized Official - Last Name:LOVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-859-7546
Mailing Address - Street 1:201 BLUEBIRD DR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-2301
Mailing Address - Country:US
Mailing Address - Phone:615-859-7546
Mailing Address - Fax:615-851-7760
Practice Address - Street 1:201 BLUEBIRD DR
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-2301
Practice Address - Country:US
Practice Address - Phone:615-859-7546
Practice Address - Fax:615-851-7760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMDO17949174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1235116518OtherNPI #
TN3708943OtherMEDICARE GROUP #
TNA99313Medicare UPIN
TN3029228Medicare PIN