1700016805 NPI number — RIVERSIDE PHYSICIAN SERVICES, INC

Table of content: MS. MAIDEN ELIZABETH CARNES ED S, LCMHCA (NPI 1396345617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700016805 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:
Provider Other Organization Name Type Code:
6
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:
1700016805
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2024
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
Provider Second Line Business Mailing Address:
STE A
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:
757-594-4006
Provider Business Mailing Address Fax Number:
757-534-5190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3700 BATTERY BLVD STE 100
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:
23185-4888
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-838-5055
Provider Business Practice Location Address Fax Number:
757-827-0129
Provider Enumeration Date:
07/23/2009

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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