Basic Information
| Provider Information | |||||||||
| NPI: | 1780879510 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERSIDE EYE CENTER PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 193 MAIN ST | ||||||||
| Address2: | RIVERSIDE EYE CENTER | ||||||||
| City: | NORWAY | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042685645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077430027 | ||||||||
| FaxNumber: | 2077430051 | ||||||||
| Practice Location | |||||||||
| Address1: | 193 MAIN ST | ||||||||
| Address2: | RIVERSIDE EYE CENTER | ||||||||
| City: | NORWAY | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042685645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077430027 | ||||||||
| FaxNumber: | 2077430051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2007 | ||||||||
| LastUpdateDate: | 06/06/2013 | ||||||||
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| AuthorizedOfficialLastName: | ROSENBERG | ||||||||
| AuthorizedOfficialFirstName: | TAMI | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2077430027 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 015596 | ME | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | NX3033 | 01 | MEDICARE PTAN | OTHER | MM8909 | 01 | MEDICARE | OTHER | 061139 | 01 | ANTHEM | OTHER | 325120099 | 05 | ME | MEDICAID | P00184354 | 01 | RAILROAD MEDICARE | OTHER | M2307901 | 01 | CIGNA | OTHER | 431545400 | 05 | ME | MEDICAID |