MEDICARE: RIVERSIDE PEDIATRIC GROUP, PC

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1770021511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERSIDE PEDIATRIC GROUP, PC

Provider Business Mailing Address
First Line	:	38 MEADOWLANDS PKWY
Second Line	:
City	:	SECAUCUS
State	:	NJ
Zip	:	07094-2925
Country	:	US
Telephone Number	:	551-257-7038
Fax Number	:

Provider Business Practice Location Address
First Line	:	2761 JOHN F KENNEDY BLVD
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07306-5515
Country	:	US
Telephone Number	:	201-653-7030
Fax Number	:	201-792-0576

Authorized Official
Title or Position	:	PRINCIPAL
Name	:	ZEYAD BAKER
Credential	:	MD
Telephone Number	:	551-257-7038

Provider Enumeration Date	:	02/01/2017
Last Update Date	:	02/15/2017

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