Provider Demographics
NPI:1649509282
Name:RIVERSIDE HOSPITAL INC
Entity type:Organization
Organization Name:RIVERSIDE 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:757-875-7543
Mailing Address - Street 1:608 DENBIGH BLVD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-4410
Mailing Address - Country:US
Mailing Address - Phone:757-875-7545
Mailing Address - Fax:757-875-7553
Practice Address - Street 1:500 J CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1929
Practice Address - Country:US
Practice Address - Phone:757-594-3756
Practice Address - Fax:757-594-2196
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERSIDE HOSPITAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA12933416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport