Basic Information
| Provider Information | |||||||||
| NPI: | 1265662365 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERSIDE PHYSICIAN SERVICES, INC | ||||||||
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| OtherOrganizationName: | CARDIOVASCULAR CENTER OF HAMPTON ROADS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 856 J CLYDE MORRIS BLVD | ||||||||
| Address2: | STE A | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236011318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575944006 | ||||||||
| FaxNumber: | 7575942195 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 SHADY LN | ||||||||
| Address2: | |||||||||
| City: | WHITE STONE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 225782601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046945553 | ||||||||
| FaxNumber: | 8046948232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2009 | ||||||||
| LastUpdateDate: | 07/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | PADDEN | ||||||||
| AuthorizedOfficialFirstName: | ERNEST | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7575944006 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.