Provider Demographics
NPI: | 1477922920 |
---|---|
Name: | RIVERSIDE SPINE & PAIN PHYSICIANS, LLC |
Entity Type: | Organization |
Organization Name: | RIVERSIDE SPINE & PAIN PHYSICIANS, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | MEDICAL DIRECTOR |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | STEPHEN |
Authorized Official - Middle Name: | SCOTT |
Authorized Official - Last Name: | KRAMARICH |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 904-389-1010 |
Mailing Address - Street 1: | 7207 GOLDEN WINGS RD |
Mailing Address - Street 2: | SUITE 100 |
Mailing Address - City: | JACKSONVILLE |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32244-3324 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 904-389-1010 |
Mailing Address - Fax: | 904-389-1082 |
Practice Address - Street 1: | 2453 US HIGHWAY 17 |
Practice Address - Street 2: | SUITE G |
Practice Address - City: | RICHMOND HILL |
Practice Address - State: | GA |
Practice Address - Zip Code: | 31324-5959 |
Practice Address - Country: | US |
Practice Address - Phone: | 904-389-1010 |
Practice Address - Fax: | 904-389-1082 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2015-09-15 |
Last Update Date: | 2015-09-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist | Group - Single Specialty |