Healthcare Provider Details

I. General information

NPI: 1730106196
Provider Name (Legal Business Name): RIVERSIDE FAMILY PRACTICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 05/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 TEANECK RD
TEANECK NJ
07666-4245
US

IV. Provider business mailing address

718 TEANECK RD
TEANECK NJ
07666-4245
US

V. Phone/Fax

Practice location:
  • Phone: 201-833-3909
  • Fax: 201-833-7073
Mailing address:
  • Phone: 201-833-3000
  • Fax: 201-227-6207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA05312800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MA06291500
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA03273300
License Number StateNJ

VIII. Authorized Official

Name: ADAM JARRETT
Title or Position: CMO, M.D.
Credential: M.D.
Phone: 201-833-3000