Provider Demographics
NPI:1821173857
Name:RIVERSIDE MEDICAL ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:RIVERSIDE MEDICAL ASSOCIATES, PLLC
Other - Org Name:RIVERSIDE MEDICAL ASSOCIATES, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRETA
Authorized Official - Middle Name:B
Authorized Official - Last Name:TEMPLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-667-5296
Mailing Address - Street 1:PO BOX 1348
Mailing Address - Street 2:
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-1348
Mailing Address - Country:US
Mailing Address - Phone:336-667-5296
Mailing Address - Fax:336-667-0864
Practice Address - Street 1:702 13TH ST
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-4075
Practice Address - Country:US
Practice Address - Phone:336-667-5296
Practice Address - Fax:336-667-0864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24818207R00000X
NC100774363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02559OtherBCBSNC
NC6902559Medicaid
1428Medicare ID - Type Unspecified
NC02559OtherBCBSNC