Provider Demographics
NPI:1306980263
Name:RIVERSIDE FAMILY MEDICAL
Entity type:Organization
Organization Name:RIVERSIDE FAMILY MEDICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:W
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:678-407-2222
Mailing Address - Street 1:1960 RIVERSIDE PKWY STE 106
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5945
Mailing Address - Country:US
Mailing Address - Phone:678-407-2222
Mailing Address - Fax:678-407-2266
Practice Address - Street 1:1960 RIVERSIDE PKWY STE 106
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5945
Practice Address - Country:US
Practice Address - Phone:678-407-2222
Practice Address - Fax:678-407-2266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034091207Q00000X
GA049316208100000X
GA002087363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty