Provider Demographics
NPI:1013060359
Name:RIVERS EDGE FAMILY MEDICINE
Entity Type:Organization
Organization Name:RIVERS EDGE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KLECAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-295-3705
Mailing Address - Street 1:330 WINDING RIVER LANE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-3551
Mailing Address - Country:US
Mailing Address - Phone:434-295-3705
Mailing Address - Fax:434-295-3705
Practice Address - Street 1:330 WINDING RIVER LANE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-3551
Practice Address - Country:US
Practice Address - Phone:434-295-3705
Practice Address - Fax:434-295-3705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054576207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA187671OtherANTHEM
VA408456OtherSOUTHERN HEALTH
VA010259231Medicaid
VAG30822Medicare UPIN
VAC09773Medicare PIN
VA00W987R73Medicare PIN