MEDICARE: RIVER CITY MEDICAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	5641	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366550956
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER CITY MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	PO BOX 15470
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95851-0470
Country	:	US
Telephone Number	:	916-228-4300
Fax Number	:	916-382-4202

Provider Business Practice Location Address
First Line	:	2727 W CAPITOL AVE
Second Line	:
City	:	WEST SACRAMENTO
State	:	CA
Zip	:	95691-2220
Country	:	US
Telephone Number	:	916-371-2275
Fax Number	:	916-371-8649

Authorized Official
Title or Position	:	COO
Name	:	MR. KENDRICK QUE
Credential	:
Telephone Number	:	916-228-4300

Provider Enumeration Date	:	08/25/2006
Last Update Date	:	04/01/2016

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