MEDICARE: RIVERFRONT PHYSICAL MEDICINE 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	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician

General Provider Information

NPI Number	:	1740798784
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERFRONT PHYSICAL MEDICINE LLC

Provider Business Mailing Address
First Line	:	PO BOX 3817
Second Line	:
City	:	WILMINGTON
State	:	DE
Zip	:	19807-0817
Country	:	US
Telephone Number	:	302-540-9187
Fax Number	:	302-777-0944

Provider Business Practice Location Address
First Line	:	131 S WEST ST
Second Line	:
City	:	WILMINGTON
State	:	DE
Zip	:	19801-5014
Country	:	US
Telephone Number	:	302-777-9355
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	GINA M GRAVES
Credential	:
Telephone Number	:	302-540-9187

Provider Enumeration Date	:	01/11/2018
Last Update Date	:	01/11/2018

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