Provider Demographics
NPI:1639660194
Name:RIVER VALLEY PEDIATRICS AND ADOLESCENT MEDICINE
Entity Type:Organization
Organization Name:RIVER VALLEY PEDIATRICS AND ADOLESCENT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:MADELINE
Authorized Official - Last Name:BIRD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-532-0525
Mailing Address - Street 1:2 DEEP HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06412-1112
Mailing Address - Country:US
Mailing Address - Phone:860-532-0525
Mailing Address - Fax:860-483-5134
Practice Address - Street 1:20 WATER ST
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:CT
Practice Address - Zip Code:06412
Practice Address - Country:US
Practice Address - Phone:401-490-1289
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-21
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT53136261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008080251Medicaid