Provider Demographics
NPI:1639571052
Name:LITTLE RIVER MEDICAL GROUP
Entity Type:Organization
Organization Name:LITTLE RIVER MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:P
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-446-4500
Mailing Address - Street 1:5656 BEE CAVES RD
Mailing Address - Street 2:SUITE M 300
Mailing Address - City:WEST LAKE HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:78746-5280
Mailing Address - Country:US
Mailing Address - Phone:512-807-3270
Mailing Address - Fax:
Practice Address - Street 1:5656 BEE CAVES RD
Practice Address - Street 2:SUITE M 300
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-5280
Practice Address - Country:US
Practice Address - Phone:512-807-3270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty