1639418429 NPI number — RIVERSIDE PHYSICIAN SERVICES INC

Table of content: (NPI 1639418429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639418429 NPI number — RIVERSIDE PHYSICIAN SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE PHYSICIAN SERVICES 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:
RIVERSIDE EMERGENCY PHYSICIANS
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:
1639418429
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 75774
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21275-5774
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-898-7012
Provider Business Mailing Address Fax Number:
904-805-1037

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 COMMONWEALTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLIAMSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23185-5229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-585-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/14/2013

Additional Information

Authorized Official

Authorized Official Last Name:
LESNICK
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
757-594-4006

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 017192800 . 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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