Provider Demographics
NPI:1093189797
Name:RIVERSIDE MEDICAL CENTER
Entity Type:Organization
Organization Name:RIVERSIDE MEDICAL CENTER
Other - Org Name:RIVERSIDE PEDIATRICS AND INTERNAL MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCGRAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-795-4168
Mailing Address - Street 1:1900 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70438-3688
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:FRANKLINTON
Practice Address - State:LA
Practice Address - Zip Code:70438-3633
Practice Address - Country:US
Practice Address - Phone:985-795-4294
Practice Address - Fax:985-839-0948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-18
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2432630Medicaid