Provider Demographics
NPI:1720707474
Name:RIVERSIDE PEDIATRIC GROUP PC
Entity Type:Organization
Organization Name:RIVERSIDE PEDIATRIC GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:GAURANG
Authorized Official - Middle Name:RAVAJI
Authorized Official - Last Name:BRAHMBHATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:551-257-7030
Mailing Address - Street 1:1 HARMON PLZ FL 10
Mailing Address - Street 2:
Mailing Address - City:SECAUCUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07094-2803
Mailing Address - Country:US
Mailing Address - Phone:201-636-7233
Mailing Address - Fax:
Practice Address - Street 1:167 AVENUE AT THE CMN
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702-4805
Practice Address - Country:US
Practice Address - Phone:732-389-2555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERSIDE PEDIATRIC GROUP, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies