1225576069 NPI number — RIVERSIDE PEDIATRIC GROUP, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225576069 NPI number — RIVERSIDE PEDIATRIC GROUP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE PEDIATRIC GROUP, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
RIVERSIDE MEDICAL GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225576069
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38 MEADOWLANDS PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SECAUCUS
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07094-2925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
551-257-7038
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 HUDSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOBOKEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07030-5305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-942-9314
Provider Business Practice Location Address Fax Number:
201-942-9315
Provider Enumeration Date:
02/01/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BAKER
Authorized Official First Name:
ZEYAD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRINCIPAL
Authorized Official Telephone Number:
551-257-7038

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)