Provider Demographics
NPI:1134303977
Name:RIVERSIDE INTERNAL MEDICINE
Entity Type:Organization
Organization Name:RIVERSIDE INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:N
Authorized Official - Last Name:BOSIDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-637-0057
Mailing Address - Street 1:1200 E PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CT
Mailing Address - Zip Code:06878-1430
Mailing Address - Country:US
Mailing Address - Phone:203-637-0057
Mailing Address - Fax:203-637-3280
Practice Address - Street 1:1200 E PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CT
Practice Address - Zip Code:06878-1430
Practice Address - Country:US
Practice Address - Phone:203-637-0057
Practice Address - Fax:203-637-3280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035452174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
010035452CT01OtherANTHEM BLUE CROSS
CTP479423OtherOXFORD
NY78467OtherEMPIRE BLUE CROSS
CTOV9649OtherHEALTH NET
010035452CT01OtherANTHEM BLUE CROSS
G38917Medicare UPIN