Provider Demographics
NPI:1104847854
Name:RIVERSIDE PHYSICIAN SERVICES INC
Entity Type:Organization
Organization Name:RIVERSIDE PHYSICIAN SERVICES INC
Other - Org Name:MIDDLE PENINSULA GENERAL AND VASCULAR SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DOUCETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-594-4006
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:757-594-2195
Practice Address - Street 1:7547 MEDICAL DRIVE
Practice Address - Street 2:SUITE 1500
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061
Practice Address - Country:US
Practice Address - Phone:804-693-3081
Practice Address - Fax:804-693-3283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC03953Medicare PIN
VAC09161Medicare PIN