Provider Demographics
NPI:1265453823
Name:RIVERSIDE PHYSICIAN SERVICES INC
Entity Type:Organization
Organization Name:RIVERSIDE PHYSICIAN SERVICES INC
Other - Org Name:RIVERSIDE GASTROENTEROLOGY SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRADEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-316-5906
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:757-534-5190
Practice Address - Street 1:850 ENTERPRISE PKWY STE 2000
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6252
Practice Address - Country:US
Practice Address - Phone:757-599-6333
Practice Address - Fax:757-591-7261
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERSIDE HEALTHCARE ASSOCIATES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-21
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC03953Medicare PIN
VAC03953Medicare PIN