Provider Demographics
NPI:1598760498
Name:RIVERSIDE MIDDLE PENINSULA HOSPITAL INC
Entity Type:Organization
Organization Name:RIVERSIDE MIDDLE PENINSULA HOSPITAL INC
Other - Org Name:RIVERSIDE WALTER REED HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:W
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:757-875-7545
Mailing Address - Street 1:608 DENBIGH BLVD STE 800
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-4487
Mailing Address - Country:US
Mailing Address - Phone:757-875-7545
Mailing Address - Fax:757-875-7553
Practice Address - Street 1:7358 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-5130
Practice Address - Country:US
Practice Address - Phone:804-693-1111
Practice Address - Fax:804-210-1449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA491530251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4910214Medicaid
VA491530Medicare ID - Type UnspecifiedPROVIDER NUMBER