Provider Demographics
NPI:1740548825
Name:RIVER VALLEY ORTHOPEDICS, PC
Entity type:Organization
Organization Name:RIVER VALLEY ORTHOPEDICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REVENUE CYCLE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-459-7101
Mailing Address - Street 1:350 LAFAYETTE AVE SE FL 4
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4656
Mailing Address - Country:US
Mailing Address - Phone:616-456-8515
Mailing Address - Fax:616-233-1108
Practice Address - Street 1:2373 64TH ST SW STE 2500
Practice Address - Street 2:
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-7978
Practice Address - Country:US
Practice Address - Phone:616-456-8515
Practice Address - Fax:616-233-1108
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVER VALLEY ORTHOPEDICS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-26
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207X00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M51600Medicare PIN