1821173857 NPI number — RIVERSIDE MEDICAL ASSOCIATES, PLLC

Table of content: (NPI 1821173857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821173857 NPI number — RIVERSIDE MEDICAL ASSOCIATES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE MEDICAL ASSOCIATES, PLLC
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 ASSOCIATES, PLLC
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:
1821173857
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1348
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH WILKESBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28659-1348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-667-5296
Provider Business Mailing Address Fax Number:
336-667-0864

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 13TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH WILKESBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28659-4075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-667-5296
Provider Business Practice Location Address Fax Number:
336-667-0864
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TEMPLETON
Authorized Official First Name:
GRETA
Authorized Official Middle Name:
B
Authorized Official Title or Position:
INSURANCE MANAGER
Authorized Official Telephone Number:
336-667-5296

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  24818 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AM0700X , with the licence number: 100774 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 02559 . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 6902559 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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