Provider Demographics
NPI:1609257310
Name:RIVERSIDE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:RIVERSIDE SURGERY CENTER, LLC
Other - Org Name:RIVERSIDE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JANA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-426-2188
Mailing Address - Street 1:3556 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2509
Mailing Address - Country:US
Mailing Address - Phone:678-426-2188
Mailing Address - Fax:770-874-8950
Practice Address - Street 1:3556 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2509
Practice Address - Country:US
Practice Address - Phone:478-475-9204
Practice Address - Fax:478-475-9572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical