1053104638 NPI number — RIVERSIDE PHYSCIAN SERVICES INC

Table of content: (NPI 1053104638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053104638 NPI number — RIVERSIDE PHYSCIAN SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE PHYSCIAN 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:
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:
1053104638
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
856 J CLYDE MORRIS BLVD STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT NEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23601-1318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-316-5800
Provider Business Mailing Address Fax Number:
757-534-5190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19375 BENNS GRANT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMITHFIELD
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23430-6393
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-534-9988
Provider Business Practice Location Address Fax Number:
757-534-5688
Provider Enumeration Date:
05/27/2025

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
BILLIE JO
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
757-316-5901

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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