Healthcare Provider Details

I. General information

NPI: 1770617664
Provider Name (Legal Business Name): RIVERDALE FAMILY MEDICINE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 E MARKET ST
SMITHFIELD NC
27577-3915
US

IV. Provider business mailing address

PO BOX 760
SMITHFIELD NC
27577-0760
US

V. Phone/Fax

Practice location:
  • Phone: 919-967-6646
  • Fax:
Mailing address:
  • Phone: 919-967-6646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9801124
License Number StateNC

VIII. Authorized Official

Name: DR. MARIE L ZALDIVAR
Title or Position: PRESIDENT
Credential: M.D.
Phone: 919-967-6646