Provider Demographics
NPI:1649218009
Name:RIVER DRIVE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:RIVER DRIVE SURGERY CENTER, LLC
Other - Org Name:RIVER DRIVE SURGERY AND LASER CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:E
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:1A BURTON HILLS BLVD # L&C
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6187
Mailing Address - Country:US
Mailing Address - Phone:615-665-1283
Mailing Address - Fax:615-234-1720
Practice Address - Street 1:619 RIVER DRIVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:ELMWOOD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07407
Practice Address - Country:US
Practice Address - Phone:201-703-2900
Practice Address - Fax:201-703-5246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2022-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22631261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2225369OtherAETNA USHC
01000333400OtherAMERICHOICE 9/1/01
0003895000OtherAMERIHEALTH
006973OtherEMPIRE BLUE YLD YLK YLA
NJ8027706Medicaid
0103113OtherGHI NON PAR
51842OtherAMERIGROUP VSP 10/25/01
0103113OtherGHI NON PAR
006973OtherEMPIRE BLUE YLD YLK YLA
=========OtherAPWU MULTIPLAN NETW
=========OtherGEHA
=========OtherFIRST HEAL STATE FARM 8/4
NJ028327Medicare ID - Type Unspecified
=========OtherAARP 4/1/00
=========OtherALICARE NON PAR
=========OtherBEECH STREET
=========OtherCIGNA PROVIDER #2656025
=========OtherEHC ALICARE UNT PREFIX NO
51842OtherAMERIGROUP VSP 10/25/01
NJ8027706Medicaid