Provider Demographics
NPI: | 1710020623 |
---|---|
Name: | RIVERSIDE PHYSICIAN SERVICES, INC. |
Entity Type: | Organization |
Organization Name: | RIVERSIDE PHYSICIAN SERVICES, INC. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | VICE PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JAMES |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | LESNICK |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 757-594-4006 |
Mailing Address - Street 1: | PO BOX 826608 |
Mailing Address - Street 2: | |
Mailing Address - City: | PHILADELPHIA |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 19182-6608 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 757-316-5888 |
Mailing Address - Fax: | 754-594-4005 |
Practice Address - Street 1: | 856 J CLYDE MORRIS BLVD |
Practice Address - Street 2: | SUITE A |
Practice Address - City: | NEWPORT NEWS |
Practice Address - State: | VA |
Practice Address - Zip Code: | 23601-1318 |
Practice Address - Country: | US |
Practice Address - Phone: | 757-594-4006 |
Practice Address - Fax: | 757-534-5190 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | RIVERSIDE HEALTHCARE ASSOCIATES INC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2007-02-14 |
Last Update Date: | 2017-02-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
VA | 207L00000X, 207Q00000X, 207R00000X, 207W00000X, 207X00000X, 207XX0005X, 207Y00000X, 208100000X, 2084N0400X, 2085R0001X, 208600000X, 2086S0129X, 208800000X, 208G00000X, 208M00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Multi-Specialty | |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 207XX0005X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | Group - Multi-Specialty |
No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
No | 2085R0001X | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 2086S0129X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | Group - Multi-Specialty |
No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
VA | C03953 | Medicare PIN |