Provider Demographics
NPI:1902675556
Name:RIVERSTONE MEDICAL, PLLC
Entity Type:Organization
Organization Name:RIVERSTONE MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALID
Authorized Official - Middle Name:AMRO
Authorized Official - Last Name:HARARAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-688-0210
Mailing Address - Street 1:35 W BROADWAY STE 102
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-2187
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:688 E VINE ST STE 16
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5541
Practice Address - Country:US
Practice Address - Phone:801-688-0210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-25
Last Update Date:2023-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty