Provider Demographics
NPI:1518918556
Name:RIVERSIDE ANESTHESIA LLC
Entity Type:Organization
Organization Name:RIVERSIDE ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:R (RUSTY)
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:318-336-2220
Mailing Address - Street 1:241 AIMEE RD
Mailing Address - Street 2:
Mailing Address - City:FERRIDAY
Mailing Address - State:LA
Mailing Address - Zip Code:71334-9615
Mailing Address - Country:US
Mailing Address - Phone:318-336-2220
Mailing Address - Fax:318-336-6060
Practice Address - Street 1:241 AIMEE RD
Practice Address - Street 2:
Practice Address - City:FERRIDAY
Practice Address - State:LA
Practice Address - Zip Code:71334-9615
Practice Address - Country:US
Practice Address - Phone:318-336-2220
Practice Address - Fax:318-336-6060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374700000XNursing Service Related ProvidersTechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04321278Medicaid
KY1447561Medicaid
LA5CK20Medicare PIN
KY1447561Medicaid