Basic Information
| Provider Information | |||||||||
| NPI: | 1487960134 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVERSIDE PHYSICIAN SERVICES, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RIVERSIDE EASTERN SHORE PHYSICIANS AND SURGEONS | ||||||||
| 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: | 7575345190 | ||||||||
| Practice Location | |||||||||
| Address1: | 9524 HOSPITAL AVE | ||||||||
| Address2: | |||||||||
| City: | NASSAWADOX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574426600 | ||||||||
| FaxNumber: | 7574423839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2010 | ||||||||
| LastUpdateDate: | 09/27/2011 | ||||||||
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| AuthorizedOfficialLastName: | LESNICK | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENTQ | ||||||||
| AuthorizedOfficialTelephone: | 7575944006 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RIVERSIDE PHYSICIAN SERVICES, INC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 213E00000X | VA | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.