Provider Demographics
NPI:1699724559
Name:RIVERSIDE OB GYN P C
Entity type:Organization
Organization Name:RIVERSIDE OB GYN P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:I
Authorized Official - Last Name:AL-JERDI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-675-7210
Mailing Address - Street 1:2275 W JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2114
Mailing Address - Country:US
Mailing Address - Phone:734-675-7210
Mailing Address - Fax:734-675-3023
Practice Address - Street 1:2275 W JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-2114
Practice Address - Country:US
Practice Address - Phone:734-675-7210
Practice Address - Fax:734-675-3023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI160055737OtherRAILROAD MEDICARE
MI4471183-11Medicaid
MI1540358-11Medicaid
MI160003353OtherRAILROAD MEDICARE
MI2966851OtherCIGNA
MI160055739OtherRAILROAD MEDICARE
MI160059461OtherRAILROAD MEDICARE
MI160H210680OtherBCBS
MI6676861OtherCIGNA
MI4165045-10Medicaid
MI7139017OtherCIGNA
MI4106545-11Medicaid
MI160059461OtherRAILROAD MEDICARE
MI160H210680OtherBCBS
MI=========OtherPPOM
MI=========OtherPPOM
MI4471183-11Medicaid
MI0G24657Medicare PIN