Healthcare Provider Details

I. General information

NPI: 1972691228
Provider Name (Legal Business Name): RIVERSIDE PSYCHIATRIC MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 12/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5887 BROCKTON AVE STE A RIVERSIDE PSYCHIATRIC MEDICAL GROUP
RIVERSIDE CA
92506
US

IV. Provider business mailing address

5887 BROCKTON AVE STE A RIVERSIDE PSYCHIATRIC MEDICAL GROUP
RIVERSIDE CA
92506
US

V. Phone/Fax

Practice location:
  • Phone: 951-275-8500
  • Fax: 951-275-8560
Mailing address:
  • Phone: 951-275-8500
  • Fax: 951-275-8560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT B. SUMMEROUR
Title or Position: OWNER
Credential: MD
Phone: 951-275-8500