Provider Demographics
NPI:1316253628
Name:RIVERSIDE GENERAL HOSPITAL MEDICAL CLINIC
Entity type:Organization
Organization Name:RIVERSIDE GENERAL HOSPITAL MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EARNEST
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:713-526-2441
Mailing Address - Street 1:3204 ENNIS ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-3213
Mailing Address - Country:US
Mailing Address - Phone:713-526-2441
Mailing Address - Fax:713-526-3554
Practice Address - Street 1:3204 ENNIS ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-3213
Practice Address - Country:US
Practice Address - Phone:713-526-2441
Practice Address - Fax:713-526-3554
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX460261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care