Provider Demographics
NPI:1417237306
Name:RIVERSIDE NEPHROLOGY
Entity Type:Organization
Organization Name:RIVERSIDE NEPHROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:HADDAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-686-4343
Mailing Address - Street 1:50 PROSPECT ST
Mailing Address - Street 2:SUITE301
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01841-2841
Mailing Address - Country:US
Mailing Address - Phone:978-686-4343
Mailing Address - Fax:978-682-5191
Practice Address - Street 1:50 PROSPECT ST
Practice Address - Street 2:SUITE301
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841-2841
Practice Address - Country:US
Practice Address - Phone:978-686-4343
Practice Address - Fax:978-682-5191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA46060207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA34727Medicare UPIN