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General NPI Number Information
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NPI Number | 1972677656
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Entity Type | Organization
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Legal Business Name | RIVERWOOD FAMILY MEDICINE PC
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Dates
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Enumeration Date | 11/17/2006
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Last Update Date | 04/21/2011
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Provider Practice Location Address
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Address Line | 3299 CLEAR VISTA CT NE SUITE C
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City | GRAND RAPIDS
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State | MI
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Zip | 49525-9477
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Country | US
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Telephone | 616-361-1200
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Fax | 616-361-2198
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Provider Business Mailing Address
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Address Line | 3299 CLEAR VISTA CT NE SUITE C
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City | GRAND RAPIDS
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State | MI
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Zip | 49525-9477
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Country | US
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Telephone | 616-361-1200
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Fax | 616-361-2198
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | DR. RANDALL N CLARK
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Credential | M.D.
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Telephone | 616-361-1178
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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 |
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