Provider Demographics
NPI:1134271208
Name:RIVERSIDE TAPPAHANNOCK HOSPITAL INC
Entity type:Organization
Organization Name:RIVERSIDE TAPPAHANNOCK HOSPITAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT-CFO
Authorized Official - Prefix:
Authorized Official - First Name:WADE
Authorized Official - Middle Name:DUDLEY
Authorized Official - Last Name:BROUGHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-591-7019
Mailing Address - Street 1:606 DENBIGH BLVD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-4413
Mailing Address - Country:US
Mailing Address - Phone:757-875-7545
Mailing Address - Fax:757-875-7553
Practice Address - Street 1:618 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560-5000
Practice Address - Country:US
Practice Address - Phone:804-443-3311
Practice Address - Fax:804-443-6150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH1889275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA49U084Medicare ID - Type Unspecified