Provider Demographics
NPI:1962404129
Name:RIVERSIDE MEDICAL INC
Entity type:Organization
Organization Name:RIVERSIDE MEDICAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-750-0018
Mailing Address - Street 1:1019 TOWN DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND HEIGHTS
Mailing Address - State:KY
Mailing Address - Zip Code:41076-9114
Mailing Address - Country:US
Mailing Address - Phone:859-441-8876
Mailing Address - Fax:859-441-5850
Practice Address - Street 1:275 EUREKA ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TN
Practice Address - Zip Code:38372-3033
Practice Address - Country:US
Practice Address - Phone:731-926-2677
Practice Address - Fax:731-926-2687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0122332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1452119Medicaid