1982933842 NPI number — RIVERSIDE GYN INC

Table of content: (NPI 1982933842)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982933842 NPI number — RIVERSIDE GYN INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE GYN 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:
1982933842
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5777 KELLOGG AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-232-3232
Provider Business Mailing Address Fax Number:
513-232-3202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5777 KELLOGG AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45230-7142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-232-3232
Provider Business Practice Location Address Fax Number:
513-333-3024
Provider Enumeration Date:
12/23/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
TARI
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
513-232-3232

Provider Taxonomy Codes

  • Taxonomy code: 173000000X , with the licence number:  35058827 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 173000000X , with the licence number: OH048288 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 6418350001 . This is a "MEDICARE DME" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2565139 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0605652 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".