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General NPI Number Information
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NPI Number | 1275687113
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Entity Type | Organization
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Legal Business Name | RIVER VALLEY FAMILY PRACTICE LTD
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Dates
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Enumeration Date | 01/22/2007
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Last Update Date | 10/11/2007
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Provider Practice Location Address
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Address Line | 2550 24TH ST
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City | ROCK ISLAND
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State | IL
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Zip | 61201-5304
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Country | US
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Telephone | 309-793-4223
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Fax | 309-793-6276
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Provider Business Mailing Address
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Address Line | 602 35TH AVE
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City | MOLINE
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State | IL
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Zip | 61265-6145
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Country | US
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Telephone | 309-736-4173
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Fax | 309-797-5653
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Authorized Official
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Title or Position | DOCTOR
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Name | DAVID GANNON
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Credential | M.D.
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Telephone | 309-739-4223
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State | IL
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