Healthcare Provider Details

I. General information

NPI: 1609090927
Provider Name (Legal Business Name): RIVERSIDE SURGICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 RUE DE SANTE SUITE 2
LAPLACE LA
70068-5400
US

IV. Provider business mailing address

501 RUE DE SANTE SUITE 2
LAPLACE LA
70068-5400
US

V. Phone/Fax

Practice location:
  • Phone: 985-652-7880
  • Fax: 985-652-7883
Mailing address:
  • Phone: 985-652-7880
  • Fax: 985-652-7883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number15420R
License Number StateLA

VIII. Authorized Official

Name: DR. BRADFORD R THOMPSON
Title or Position: MANAGER
Credential: MD
Phone: 985-652-7880