Basic Information
| Provider Information | |||||||||
| NPI: | 1790049252 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERSIDE PHYSICIAN SERVICES INC | ||||||||
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| OtherOrganizationName: | RIVERSIDE NORTHERN NECK BONE AND JOINT CENTER | ||||||||
| 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: | 300 MT CLEMENT PARK | ||||||||
| Address2: | SUITE B | ||||||||
| City: | TAPPAHANNOCK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 225605098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8044438670 | ||||||||
| FaxNumber: | 8044438675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2012 | ||||||||
| LastUpdateDate: | 08/27/2012 | ||||||||
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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 | 207X00000X | 0101248828 | VA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | 0101248828 | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
No ID Information.