Provider Demographics
NPI:1053867598
Name:RIVERSIDE MEDICAL GROUP
Entity Type:Organization
Organization Name:RIVERSIDE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:JD, MPP
Authorized Official - Phone:201-774-0149
Mailing Address - Street 1:714 10TH ST
Mailing Address - Street 2:
Mailing Address - City:SECAUCUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07094-2921
Mailing Address - Country:US
Mailing Address - Phone:201-865-2050
Mailing Address - Fax:
Practice Address - Street 1:714 10TH ST
Practice Address - Street 2:
Practice Address - City:SECAUCUS
Practice Address - State:NJ
Practice Address - Zip Code:07094-2921
Practice Address - Country:US
Practice Address - Phone:201-865-2050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00655100363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty