Healthcare Provider Details

I. General information

NPI: 1245286210
Provider Name (Legal Business Name): RIVERSIDE FAMILY PRACTICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3129 BLATTNER DR
CAPE GIRARDEAU MO
63703-6364
US

IV. Provider business mailing address

3129 BLATTNER DR
CAPE GIRARDEAU MO
63703-6364
US

V. Phone/Fax

Practice location:
  • Phone: 573-335-0166
  • Fax: 573-335-7942
Mailing address:
  • Phone: 573-335-0166
  • Fax: 573-335-7942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number32836
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2000160642
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number2000160642
License Number StateMO

VIII. Authorized Official

Name: DR. JAMES E PALEN
Title or Position: OWNER
Credential: M.D.
Phone: 573-335-0166