Provider Demographics
NPI:1093884439
Name:RIVERSIDE MEDICAL CENTER, PA
Entity Type:Organization
Organization Name:RIVERSIDE MEDICAL CENTER, PA
Other - Org Name:RIVERSIDE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JANET
Authorized Official - Middle Name:E
Authorized Official - Last Name:MILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-264-2345
Mailing Address - Street 1:3206 S HOPKINS AVE
Mailing Address - Street 2:SUITE 87
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-5667
Mailing Address - Country:US
Mailing Address - Phone:321-264-2345
Mailing Address - Fax:321-735-8882
Practice Address - Street 1:863 N COCOA BLVD
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7510
Practice Address - Country:US
Practice Address - Phone:321-264-2345
Practice Address - Fax:321-735-8882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207RC0200X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL03280OtherBCBS INSURANCE
FL7883229001OtherCIGNA INSURANCE
FL7276274OtherAETNA INSURANCE
FL7883229001OtherCIGNA INSURANCE
FLH49134Medicare UPIN