Basic Information
| Provider Information | |||||||||
| NPI: | 1942670658 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERSIDE SPINE GEORGIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6195 LAKE GRAY BLVD | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322445891 | ||||||||
| 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: | 10/07/2015 | ||||||||
| LastUpdateDate: | 10/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | STEIGER | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9043891010 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RIVERSIDE SPINE & PAIN PHYSICIANS | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | 047638 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.