Provider Demographics
NPI:1780879510
Name:RIVERSIDE EYE CENTER PA
Entity type:Organization
Organization Name:RIVERSIDE EYE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOURNIER
Authorized Official - Suffix:
Authorized Official - Credentials:CMPE
Authorized Official - Phone:207-786-1917
Mailing Address - Street 1:193 MAIN ST
Mailing Address - Street 2:RIVERSIDE EYE CENTER
Mailing Address - City:NORWAY
Mailing Address - State:ME
Mailing Address - Zip Code:04268-5645
Mailing Address - Country:US
Mailing Address - Phone:207-743-0027
Mailing Address - Fax:207-743-0051
Practice Address - Street 1:475 LISBON ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7418
Practice Address - Country:US
Practice Address - Phone:207-786-2500
Practice Address - Fax:207-786-2503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015596207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00184354OtherRAILROAD MEDICARE
061139OtherANTHEM
ME325120099Medicaid
ME431545400Medicaid
NX3033OtherMEDICARE PTAN
M2307901OtherCIGNA
MM8909OtherMEDICARE
M2307901OtherCIGNA
ME431545400Medicaid