Basic Information
| Provider Information | |||||||||
| NPI: | 1326603952 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERSIDE PHYSICAIN SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 856 J CLYDE MORRIS BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236011318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573165800 | ||||||||
| FaxNumber: | 7575345190 | ||||||||
| Practice Location | |||||||||
| Address1: | 727 25TH ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236074601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575944060 | ||||||||
| FaxNumber: | 7575944257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2019 | ||||||||
| LastUpdateDate: | 11/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | GENZLER | ||||||||
| AuthorizedOfficialFirstName: | STACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7573165959 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RIVERSIDE HEALTH CARE ASSOC | ||||||||
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| NPICertificationDate: | 11/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.