Healthcare Provider Details

I. General information

NPI: 1639236102
Provider Name (Legal Business Name): RIVERS EDGE PEDIATRICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N HIGH STREET SUITE A
DUBLIN OH
43017
US

IV. Provider business mailing address

100 N HIGH STREET SUITE A
DUBLIN OH
43017
US

V. Phone/Fax

Practice location:
  • Phone: 614-889-7772
  • Fax: 614-764-0843
Mailing address:
  • Phone: 614-889-7772
  • Fax: 614-764-0843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35059012
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35078015
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35081127
License Number StateOH

VIII. Authorized Official

Name: MRS. CHRISTINE A POPE
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 614-889-7772