Basic Information
Provider Information | |||||||||
NPI: | 1295756096 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RIVERSIDE PHYSICIAN SERVICES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RIVERSIDE MATHEWS MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 856 J CLYDE MORRIS BLVD | ||||||||
Address2: | SUITE A | ||||||||
City: | NEWPORT NEWS | ||||||||
State: | VA | ||||||||
PostalCode: | 236011318 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7575944006 | ||||||||
FaxNumber: | 7545345190 | ||||||||
Practice Location | |||||||||
Address1: | 10976 BUCKLEY HALL ROAD | ||||||||
Address2: |   | ||||||||
City: | MATHEWS | ||||||||
State: | VA | ||||||||
PostalCode: | 23109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8047255005 | ||||||||
FaxNumber: | 7577253204 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2006 | ||||||||
LastUpdateDate: | 10/15/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LESNICK | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7575944006 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | RIVERSIDE HEALTHCARE ASSOCIATES INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 207R00000X |   | VA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.