1700876703 NPI number — RIVERSIDE SURGERY CENTER INC

Table of content: (NPI 1700876703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700876703 NPI number — RIVERSIDE SURGERY CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE SURGERY CENTER INC
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:
Provider Other Organization Name Type Code:
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:
1700876703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14410 US HIGHWAY 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEBASTIAN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32958-3237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-589-8111
Provider Business Mailing Address Fax Number:
772-589-7561

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14410 US HIGHWAY 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEBASTIAN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32958-3237
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-589-8111
Provider Business Practice Location Address Fax Number:
772-589-7561
Provider Enumeration Date:
10/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DANIELS
Authorized Official First Name:
TRISH
Authorized Official Middle Name:
A
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
772-589-8111

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  1034 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 490005283 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: F1268 . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0499360 . This is a "GHI FACILITY NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 001577500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 67R . This is a "BCBS FACILITY NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 104707500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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