Provider Demographics
NPI:1477646479
Name:RIVERWOODS INTERVENTIONAL RADIOLOGY INC
Entity Type:Organization
Organization Name:RIVERWOODS INTERVENTIONAL RADIOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GIBBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-437-4895
Mailing Address - Street 1:3152 N UNIVERSITY AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4729
Mailing Address - Country:US
Mailing Address - Phone:801-437-4895
Mailing Address - Fax:801-229-1003
Practice Address - Street 1:3152 N UNIVERSITY AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4729
Practice Address - Country:US
Practice Address - Phone:801-437-4895
Practice Address - Fax:801-229-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5414031-1704261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528906826089Medicaid
UT528906826089Medicaid