Provider Demographics
NPI:1790042158
Name:RIVER RIDGE PEDIATRICS, P.A.
Entity Type:Organization
Organization Name:RIVER RIDGE PEDIATRICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ADANA
Authorized Official - Middle Name:MILLIKEN
Authorized Official - Last Name:GIPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-930-1309
Mailing Address - Street 1:1526 LEANDER RD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-8801
Mailing Address - Country:US
Mailing Address - Phone:512-930-1309
Mailing Address - Fax:512-863-5222
Practice Address - Street 1:1526 LEANDER RD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-8801
Practice Address - Country:US
Practice Address - Phone:512-930-1309
Practice Address - Fax:512-863-5222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty