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General NPI Number Information
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NPI Number | 1033496070
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Entity Type | Organization
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Legal Business Name | RIVERDALE MEDICAL CENTER LLC
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Dates
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Enumeration Date | 11/04/2011
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Last Update Date | 11/04/2011
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Provider Practice Location Address
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Address Line | 189 MEDICAL WAY SUITE B
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City | RIVERDALE
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State | GA
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Zip | 30274-4905
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Country | US
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Telephone | 770-907-2333
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Fax | 770-907-2299
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Provider Business Mailing Address
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Address Line | 189 MEDICAL WAY SUITE B
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City | RIVERDALE
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State | GA
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Zip | 30274-4905
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Country | US
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Telephone | 770-907-2333
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Fax | 770-907-2299
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Authorized Official
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Title or Position | MANAGER
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Name | SHELLY MORELAND
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Credential |
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Telephone | 404-543-6949
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number |
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number |
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number |
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License Number State | GA
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Taxonomy #4
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State | GA
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