Healthcare Provider Details

I. General information

NPI: 1407785587
Provider Name (Legal Business Name): RIVER MEDICAL PRACTICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CHAPMAN STREET RD
MORRISTOWN NY
13664-3254
US

IV. Provider business mailing address

4 FULLER ST
ALEXANDRIA BAY NY
13607-1316
US

V. Phone/Fax

Practice location:
  • Phone: 315-482-2511
  • Fax: 315-482-7506
Mailing address:
  • Phone: 315-482-2511
  • Fax: 315-482-7506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KELLEY TIERNAN
Title or Position: CEO
Credential:
Phone: 315-482-2511