Provider Demographics
NPI:1962425884
Name:RIVERSIDE PHYSICIAN SERVICES INC
Entity type:Organization
Organization Name:RIVERSIDE PHYSICIAN SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:LESNICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-594-4006
Mailing Address - Street 1:4032 CAMPBELL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-4518
Mailing Address - Country:US
Mailing Address - Phone:757-877-3956
Mailing Address - Fax:757-856-7121
Practice Address - Street 1:4032 CAMPBELL RD
Practice Address - Street 2:SUITE B
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4252
Practice Address - Country:US
Practice Address - Phone:757-877-3956
Practice Address - Fax:757-856-7121
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERSIDE PHYSICIAN SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-25
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1081570009Medicare NSC
VAC03953Medicare PIN