Provider Demographics
NPI:1487960134
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 PRESIDENTQ
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:LESNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-594-4006
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:757-534-5190
Practice Address - Street 1:9524 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:NASSAWADOX
Practice Address - State:VA
Practice Address - Zip Code:23413
Practice Address - Country:US
Practice Address - Phone:757-442-6600
Practice Address - Fax:757-442-3839
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERSIDE PHYSICIAN SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-19
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207RC0000X, 207RP1001X, 2084N0400X, 207R00000X
VA213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC03953Medicare PIN
VA1081570060Medicare NSC