Provider Demographics
NPI:1467694356
Name:RIVERSIDE MEDICAL, LLC
Entity Type:Organization
Organization Name:RIVERSIDE MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AZZAM
Authorized Official - Middle Name:ABU
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-863-3346
Mailing Address - Street 1:714 10TH ST
Mailing Address - Street 2:
Mailing Address - City:SECAUCUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07094-2921
Mailing Address - Country:US
Mailing Address - Phone:201-863-3346
Mailing Address - Fax:201-863-5251
Practice Address - Street 1:714 10TH ST
Practice Address - Street 2:
Practice Address - City:SECAUCUS
Practice Address - State:NJ
Practice Address - Zip Code:07094-2921
Practice Address - Country:US
Practice Address - Phone:201-863-3346
Practice Address - Fax:201-863-5251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty