Provider Demographics
NPI:1720407570
Name:RIVERSIDE SPINE & PHYSICAL MEDICINE, PC
Entity Type:Organization
Organization Name:RIVERSIDE SPINE & PHYSICAL MEDICINE, PC
Other - Org Name:RIVERSIDE SPINE & PHYSICAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHESTER
Authorized Official - Suffix:
Authorized Official - Credentials:CPC,CPB,CPMA,CTA
Authorized Official - Phone:931-542-9420
Mailing Address - Street 1:121 W DUNBAR CAVE RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-6037
Mailing Address - Country:US
Mailing Address - Phone:931-542-9420
Mailing Address - Fax:931-542-9422
Practice Address - Street 1:121 W DUNBAR CAVE RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-6037
Practice Address - Country:US
Practice Address - Phone:931-542-9420
Practice Address - Fax:931-542-9422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-09
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X, 208100000X, 261QP2000X
TNMD28572207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1336490266Other1336490266
TN1598899429Other1598899429