Provider Demographics
NPI:1316969215
Name:RIVERCITY PODIATRY, PC
Entity type:Organization
Organization Name:RIVERCITY PODIATRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:423-870-9988
Mailing Address - Street 1:PO BOX 4025
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-0025
Mailing Address - Country:US
Mailing Address - Phone:423-870-9988
Mailing Address - Fax:423-870-9955
Practice Address - Street 1:3107 OZARK CIR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37415-5105
Practice Address - Country:US
Practice Address - Phone:423-870-9988
Practice Address - Fax:423-870-9955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM585213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3723317Medicaid
GAGRP6421Medicare ID - Type Unspecified
TN3723317Medicare ID - Type Unspecified
TN3723317Medicaid