Provider Demographics
NPI:1811206923
Name:RIVERSIDE MEDICAL CLINIC
Entity Type:Organization
Organization Name:RIVERSIDE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-561-3300
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:MANILA
Mailing Address - State:AR
Mailing Address - Zip Code:72442-0910
Mailing Address - Country:US
Mailing Address - Phone:870-561-3300
Mailing Address - Fax:870-561-3307
Practice Address - Street 1:803 HWY 18
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:AR
Practice Address - Zip Code:72347-0505
Practice Address - Country:US
Practice Address - Phone:870-237-1055
Practice Address - Fax:870-237-1054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-07
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR187113002Medicaid
AR187113002Medicaid