Provider Demographics
NPI:1962456962
Name:RIVERSIDE PRIMARY CARE ASSOCIATES LLC
Entity type:Organization
Organization Name:RIVERSIDE PRIMARY CARE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MADHU
Authorized Official - Middle Name:MOHAN
Authorized Official - Last Name:KATIKINENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-927-7750
Mailing Address - Street 1:6510 KENILWORTH AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-1339
Mailing Address - Country:US
Mailing Address - Phone:301-927-2683
Mailing Address - Fax:301-779-8243
Practice Address - Street 1:6400 MARLBORO PIKE
Practice Address - Street 2:
Practice Address - City:DISTRICT HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20747-2841
Practice Address - Country:US
Practice Address - Phone:301-736-7000
Practice Address - Fax:301-736-6916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD749501310Medicaid
DCG00099Medicare PIN
MD749501310Medicaid