Provider Demographics
NPI:1699290239
Name:RIVERSIDE MEDICAL CENTER
Entity type:Organization
Organization Name:RIVERSIDE MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-795-4180
Mailing Address - Street 1:1900 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70438-3688
Mailing Address - Country:US
Mailing Address - Phone:985-848-9955
Mailing Address - Fax:
Practice Address - Street 1:51704 HIGHWAY 438
Practice Address - Street 2:
Practice Address - City:FRANKLINTON
Practice Address - State:LA
Practice Address - Zip Code:70438-7488
Practice Address - Country:US
Practice Address - Phone:985-848-9955
Practice Address - Fax:985-848-9964
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERSIDE MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-04
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015223207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2314394Medicaid