Provider Demographics
NPI:1912171489
Name:RIVERDALE BEHAVIORAL HEALTH, PC
Entity Type:Organization
Organization Name:RIVERDALE BEHAVIORAL HEALTH, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHITRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OLAYINKA
Authorized Official - Middle Name:OLANIYI
Authorized Official - Last Name:AKINWUMIJU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-385-2342
Mailing Address - Street 1:4700 WHITE PASS DR
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-3462
Mailing Address - Country:US
Mailing Address - Phone:901-385-2342
Mailing Address - Fax:901-382-0140
Practice Address - Street 1:8135 GOODMAN RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-2103
Practice Address - Country:US
Practice Address - Phone:662-893-7102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS169502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07686515Medicaid
MS06729219Medicaid
MS06729219Medicaid
MSH14523Medicare UPIN