Provider Demographics
NPI:1881697522
Name:RIVERSIDE PARK SURGICENTER LLC
Entity type:Organization
Organization Name:RIVERSIDE PARK SURGICENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:COLLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMAISTRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-355-9800
Mailing Address - Street 1:2001 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-3703
Mailing Address - Country:US
Mailing Address - Phone:904-355-9800
Mailing Address - Fax:904-356-8680
Practice Address - Street 1:2001 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3703
Practice Address - Country:US
Practice Address - Phone:904-355-9800
Practice Address - Fax:904-356-8680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-25
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL80003681261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL079102400Medicaid
FL101679OtherAVMED
FL17626OtherCIGNA
FL10C0001167OtherMEDICARE DMERC
FL490001993OtherRR MEDICARE
FL62JOtherBCBS
FL6800031OtherUNITED
FL079102400Medicaid