Basic Information
| Provider Information | |||||||||
| NPI: | 1477922920 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERSIDE SPINE & PAIN PHYSICIANS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7207 GOLDEN WINGS RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322443324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043891010 | ||||||||
| FaxNumber: | 9043891082 | ||||||||
| Practice Location | |||||||||
| Address1: | 2453 US HIGHWAY 17 | ||||||||
| Address2: | SUITE G | ||||||||
| City: | RICHMOND HILL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313245959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043891010 | ||||||||
| FaxNumber: | 9043891082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2015 | ||||||||
| LastUpdateDate: | 09/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | KRAMARICH | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9043891010 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.