Provider Demographics
NPI:1790742971
Name:RIVERSIDE PEDIATRICS, INC
Entity Type:Organization
Organization Name:RIVERSIDE PEDIATRICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:MANSOUR
Authorized Official - Last Name:EBRAHIMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:660-826-0027
Mailing Address - Street 1:2873 S INGRAM AVE
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-8480
Mailing Address - Country:US
Mailing Address - Phone:660-826-0027
Mailing Address - Fax:660-826-1494
Practice Address - Street 1:2873 S INGRAM AVE
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-8480
Practice Address - Country:US
Practice Address - Phone:660-826-0027
Practice Address - Fax:660-826-1494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101862261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO187630OtherHEALTHLINK INSURANCE
MO29832018OtherBLUE CROSS BLUE SHIELD
MO1200288OtherUNITED INSURANCE
MO1922V3799OtherHEALTHCARE USA
MO101990OtherFIRSTGUARD INSURANCE