Provider Demographics
NPI:1083630545
Name:RIVERSIDE PHYSICIAN SERVICES INC
Entity Type:Organization
Organization Name:RIVERSIDE PHYSICIAN SERVICES INC
Other - Org Name:HAMPTON ROADS EYE ASSOCIATES-WILLIAMSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:LESNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-594-4006
Mailing Address - Street 1:120 KINGS WAY
Mailing Address - Street 2:SUITE 1300
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-2505
Mailing Address - Country:US
Mailing Address - Phone:757-345-3001
Mailing Address - Fax:757-345-3102
Practice Address - Street 1:120 KINGS WAY
Practice Address - Street 2:SUITE 1300
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-2505
Practice Address - Country:US
Practice Address - Phone:757-345-1001
Practice Address - Fax:757-345-3102
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERSIDE HEALTHCARE ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-15
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1083630545Medicaid
VA1083630545Medicaid
VAC03953Medicare PIN