Healthcare Provider Details

I. General information

NPI: 1740798784
Provider Name (Legal Business Name): RIVERFRONT PHYSICAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2018
Last Update Date: 01/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 S WEST ST
WILMINGTON DE
19801-5014
US

IV. Provider business mailing address

PO BOX 3817
WILMINGTON DE
19807-0817
US

V. Phone/Fax

Practice location:
  • Phone: 302-777-9355
  • Fax:
Mailing address:
  • Phone: 302-540-9187
  • Fax: 302-777-0944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: GINA M GRAVES
Title or Position: ADMINISTRATOR
Credential:
Phone: 302-540-9187