Provider Demographics
NPI:1770617664
Name:RIVERDALE FAMILY MEDICINE, PA
Entity type:Organization
Organization Name:RIVERDALE FAMILY MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ZALDIVAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-967-6646
Mailing Address - Street 1:PO BOX 760
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-0760
Mailing Address - Country:US
Mailing Address - Phone:919-967-6646
Mailing Address - Fax:
Practice Address - Street 1:127 E MARKET ST
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-3915
Practice Address - Country:US
Practice Address - Phone:919-967-6646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9801124207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8911623Medicaid
NC11623OtherBCNC
NC2264608AMedicare ID - Type Unspecified
NC8911623Medicaid