Provider Demographics
NPI:1245286210
Name:RIVERSIDE FAMILY PRACTICE, PC
Entity type:Organization
Organization Name:RIVERSIDE FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:PALEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-335-0166
Mailing Address - Street 1:3129 BLATTNER DR
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6364
Mailing Address - Country:US
Mailing Address - Phone:573-335-0166
Mailing Address - Fax:573-335-7942
Practice Address - Street 1:3129 BLATTNER DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6364
Practice Address - Country:US
Practice Address - Phone:573-335-0166
Practice Address - Fax:573-335-7942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000160642207R00000X, 207RN0300X
MO32836207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO132330OtherBLUE CROSS BLUE SHIELD
MOCI5917OtherRAILROAD GROUP NUMBER