Provider Demographics
NPI:1689639254
Name:RIVERSIDE GENERAL HOSPITAL
Entity Type:Organization
Organization Name:RIVERSIDE GENERAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EARNEST
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON III
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-526-2441
Mailing Address - Street 1:3204 ENNIS ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-3213
Mailing Address - Country:US
Mailing Address - Phone:713-526-2441
Mailing Address - Fax:713-526-8754
Practice Address - Street 1:3204 ENNIS STREET
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-3213
Practice Address - Country:US
Practice Address - Phone:713-526-2441
Practice Address - Fax:713-526-8754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000460282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131040104Medicaid
TX450446Medicare ID - Type UnspecifiedCMS