Healthcare Provider Details

I. General information

NPI: 1083865554
Provider Name (Legal Business Name): RIVERTON PHYSICIAN PRACTICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 ROSE LN SUITE D
RIVERTON WY
82501-2286
US

IV. Provider business mailing address

PO BOX 758
POST FALLS ID
83877-0758
US

V. Phone/Fax

Practice location:
  • Phone: 307-856-4688
  • Fax:
Mailing address:
  • Phone: 208-773-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM M. GRACEY
Title or Position: COO
Credential:
Phone: 615-372-8500