Provider Demographics
NPI:1104290949
Name:RIVERSIDE MEDICAL CENTER
Entity type:Organization
Organization Name:RIVERSIDE MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCGRAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-795-4168
Mailing Address - Street 1:809 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70438-3635
Mailing Address - Country:US
Mailing Address - Phone:985-795-4208
Mailing Address - Fax:985-795-4210
Practice Address - Street 1:809 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:FRANKLINTON
Practice Address - State:LA
Practice Address - Zip Code:70438-3635
Practice Address - Country:US
Practice Address - Phone:985-795-4208
Practice Address - Fax:985-795-4210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-17
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA168208600000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty