Provider Demographics
NPI:1508229378
Name:RIVER CITY MEDICAL AND ARTHRITIS CENTER LLC
Entity Type:Organization
Organization Name:RIVER CITY MEDICAL AND ARTHRITIS CENTER LLC
Other - Org Name:DEDRI M IVORY MD PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEDRI
Authorized Official - Middle Name:M
Authorized Official - Last Name:IVORY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-501-6991
Mailing Address - Street 1:3510 PEMBERTON SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5506
Mailing Address - Country:US
Mailing Address - Phone:601-501-6991
Mailing Address - Fax:601-501-6987
Practice Address - Street 1:3510 PEMBERTON SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5506
Practice Address - Country:US
Practice Address - Phone:601-501-6991
Practice Address - Fax:601-501-6987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-30
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21520207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08551324Medicaid
529419Medicare PIN
MS08551324Medicaid