MEDICARE: RIVER VALLEY MEDICAL GROUP, LLC

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	261QP2300X	Primary Care Clinic/Center
2	207R00000X	Internal Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G81285	OTHER		MEDICARE

Other Identifiers

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

General Provider Information

NPI Number	:	1396408290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER VALLEY MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	4626 PROGRESS DR STE C
Second Line	:
City	:	DAVENPORT
State	:	IA
Zip	:	52807-3485
Country	:	US
Telephone Number	:	563-551-4200
Fax Number	:	563-441-9101

Provider Business Practice Location Address
First Line	:	4626 PROGRESS DR STE C
Second Line	:
City	:	DAVENPORT
State	:	IA
Zip	:	52807-3485
Country	:	US
Telephone Number	:	563-551-4200
Fax Number	:	563-441-9101

Authorized Official
Title or Position	:	PHYSICIAN/OWNER
Name	:	DR. RADHIKA N KOLLA
Credential	:	MD
Telephone Number	:	563-271-3023

Provider Enumeration Date	:	10/18/2021
Last Update Date	:	06/23/2023

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Directions to “RIVER VALLEY MEDICAL GROUP, LLC ” Practice Location

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