Healthcare Provider Details

I. General information

NPI: 1487693164
Provider Name (Legal Business Name): RIVERDEL MEDICAL PRACTICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 CLAY ST.
RIVERSIDE NJ
08075
US

IV. Provider business mailing address

302 CLAY ST.
RIVERSIDE NJ
08075
US

V. Phone/Fax

Practice location:
  • Phone: 856-461-7755
  • Fax: 856-461-2699
Mailing address:
  • Phone: 856-461-7755
  • Fax: 856-461-2699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number25MA03673200
License Number StateNJ

VIII. Authorized Official

Name: DR. EVACUETO P. TANGCO
Title or Position: OWNER
Credential: M.D.
Phone: 856-461-7755