1942670658 NPI number — RIVERSIDE SPINE GEORGIA

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 1942670658 NPI number — RIVERSIDE SPINE GEORGIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE SPINE GEORGIA
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:
1942670658
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6195 LAKE GRAY BLVD
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32244-5891
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-389-1010
Provider Business Mailing Address Fax Number:
904-389-1082

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2453 US HIGHWAY 17
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
RICHMOND HILL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31324-5959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-389-1010
Provider Business Practice Location Address Fax Number:
904-389-1082
Provider Enumeration Date:
10/07/2015

Additional Information

Authorized Official

Authorized Official Last Name:
STEIGER
Authorized Official First Name:
JASON
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
904-389-1010

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  047638 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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