Provider Demographics
NPI:1922192574
Name:FAMILY MEDICAL CARE OF RIVERVIEW PA
Entity Type:Organization
Organization Name:FAMILY MEDICAL CARE OF RIVERVIEW PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:LOUDERBACK
Authorized Official - Suffix:
Authorized Official - Credentials:CMM
Authorized Official - Phone:813-677-8418
Mailing Address - Street 1:7229 US HIGHWAY 301 S
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-4346
Mailing Address - Country:US
Mailing Address - Phone:813-677-8418
Mailing Address - Fax:813-677-8419
Practice Address - Street 1:7229 US HIGHWAY 301 S
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-4346
Practice Address - Country:US
Practice Address - Phone:813-677-8418
Practice Address - Fax:813-677-8419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263029000Medicaid
FL263029000Medicaid