1639208648 NPI number — RIVERSIDE SPINE & PAIN PHYSICIANS, LLC

Table of content: (NPI 1639208648)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639208648 NPI number — RIVERSIDE SPINE & PAIN PHYSICIANS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE SPINE & PAIN PHYSICIANS, LLC
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:
1639208648
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7207 GOLDEN WINGS RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32244-3324
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:
7207 GOLDEN WINGS RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32244-3324
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:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BALDOCK
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OFFICER AND AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
615-234-5900

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME83572 , 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: 2947648 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 34167 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 100543300 . 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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