MEDICARE: RIVERSIDE PHYSICIAN SERVICES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VG0400X	Gynecology Physician

General Provider Information

NPI Number	:	1164693206
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERSIDE PHYSICIAN SERVICES INC

Provider Business Mailing Address
First Line	:	856 J CLYDE MORRIS BLVD
Second Line	:	SUITE A
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23601-1318
Country	:	US
Telephone Number	:	757-594-4006
Fax Number	:	757-594-2195

Provider Business Practice Location Address
First Line	:	12700 MCMANUS BLVD
Second Line	:	SUITE 102A
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23602-4407
Country	:	US
Telephone Number	:	757-874-8696
Fax Number	:	757-872-9907

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MICHAEL J DOUCETTE
Credential	:
Telephone Number	:	757-594-4006

Provider Enumeration Date	:	03/17/2008
Last Update Date	:	03/17/2008

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Directions to “RIVERSIDE PHYSICIAN SERVICES INC ” Practice Location

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