Provider Demographics
NPI:1669762480
Name:RIVERSIDE GASTROENTEROLOGY PC
Entity type:Organization
Organization Name:RIVERSIDE GASTROENTEROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-260-2333
Mailing Address - Street 1:1304 SOMERVILLE RD SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-4354
Mailing Address - Country:US
Mailing Address - Phone:256-260-2333
Mailing Address - Fax:256-260-2336
Practice Address - Street 1:1304 SOMERVILLE RD SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4354
Practice Address - Country:US
Practice Address - Phone:256-260-2333
Practice Address - Fax:256-260-2336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty