Provider Demographics
NPI:1972691228
Name:RIVERSIDE PSYCHIATRIC MEDICAL GROUP
Entity Type:Organization
Organization Name:RIVERSIDE PSYCHIATRIC MEDICAL GROUP
Other - Org Name:RIVERSIDE PSYCH MED GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:SUMMEROUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-275-8500
Mailing Address - Street 1:5887 BROCKTON AVE
Mailing Address - Street 2:STE A RIVERSIDE PSYCHIATRIC MEDICAL GROUP
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506
Mailing Address - Country:US
Mailing Address - Phone:951-275-8500
Mailing Address - Fax:951-275-8560
Practice Address - Street 1:5887 BROCKTON AVE
Practice Address - Street 2:STE A RIVERSIDE PSYCHIATRIC MEDICAL GROUP
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506
Practice Address - Country:US
Practice Address - Phone:951-275-8500
Practice Address - Fax:951-275-8560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01005ZMedicare PIN