Provider Demographics
NPI:1972677656
Name:RIVERWOOD FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:RIVERWOOD FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:N
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-361-1178
Mailing Address - Street 1:3299 CLEAR VISTA CT NE
Mailing Address - Street 2:SUITE C
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9477
Mailing Address - Country:US
Mailing Address - Phone:616-361-1200
Mailing Address - Fax:616-361-2198
Practice Address - Street 1:3299 CLEAR VISTA CT NE
Practice Address - Street 2:SUITE C
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9477
Practice Address - Country:US
Practice Address - Phone:616-361-1200
Practice Address - Fax:616-361-2198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080D148480OtherBCBS GROUP NUMBER
MI0D14848Medicare ID - Type UnspecifiedGROUP NUMBER