Provider Demographics
NPI:1508257882
Name:RIVERSIDE SURGICAL ASSOCIATES, PC.
Entity Type:Organization
Organization Name:RIVERSIDE SURGICAL ASSOCIATES, PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:KAMINSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:219-902-9663
Mailing Address - Street 1:18025 FORT ST
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-7432
Mailing Address - Country:US
Mailing Address - Phone:734-785-8251
Mailing Address - Fax:734-785-8290
Practice Address - Street 1:18025 FORT ST STE B
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-7432
Practice Address - Country:US
Practice Address - Phone:219-902-9663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017755208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty