Provider Demographics
NPI:1114227394
Name:RIVERSIDE PHYSICIAN SERVICES INC
Entity Type:Organization
Organization Name:RIVERSIDE PHYSICIAN SERVICES INC
Other - Org Name:RIVERSIDE LLH - WILLIAMSBURG LANDING
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 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:757-534-5190
Practice Address - Street 1:5700 WILLIAMSBURG LANDING DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-3779
Practice Address - Country:US
Practice Address - Phone:757-565-6525
Practice Address - Fax:757-565-6551
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERSIDE HEALTHCARE ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-22
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC03953Medicare PIN