Basic Information
| Provider Information | |||||||||
| NPI: | 1447556097 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERSIDE PHYSICIAN SERVICES INC | ||||||||
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| OtherOrganizationName: | EASTERN SHORE PHYSICIAN AND SURGEONS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 856 J CLYDE MORRIS BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236011318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575944006 | ||||||||
| FaxNumber: | 7575345190 | ||||||||
| Practice Location | |||||||||
| Address1: | 9507 HOSPITAL AVE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | NASSAWADOX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574148753 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2011 | ||||||||
| LastUpdateDate: | 09/27/2011 | ||||||||
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| AuthorizedOfficialLastName: | LESNICK | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7575944006 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RIVERSIDE PHYSICIAN SERVICES INC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 0101040816 | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.