Provider Demographics
NPI:1982933842
Name:RIVERSIDE GYN INC
Entity Type:Organization
Organization Name:RIVERSIDE GYN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TARI
Authorized Official - Middle Name:S
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-232-3232
Mailing Address - Street 1:5777 KELLOGG AVENUE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45230
Mailing Address - Country:US
Mailing Address - Phone:513-232-3232
Mailing Address - Fax:513-232-3202
Practice Address - Street 1:5777 KELLOGG AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45230-7142
Practice Address - Country:US
Practice Address - Phone:513-232-3232
Practice Address - Fax:513-333-3024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-23
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35058827173000000X
OHOH048288173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6418350001OtherMEDICARE DME
OH2565139Medicaid
OH0605652Medicaid
OH0605652Medicaid
OH6418350001Medicare NSC
OH6418350001OtherMEDICARE DME