Healthcare Provider Details

I. General information

NPI: 1144308099
Provider Name (Legal Business Name): RIVERSIDE ORTHOPAEDIC & SPORTS MEDICINE ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 01/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 BROADWAY 10TH FLOOR
NEW YORK NY
10019-1412
US

IV. Provider business mailing address

1790 BROADWAY 10TH FLOOR
NEW YORK NY
10019-1412
US

V. Phone/Fax

Practice location:
  • Phone: 212-265-2828
  • Fax: 212-265-3130
Mailing address:
  • Phone: 212-265-2828
  • Fax: 212-265-3130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateNY

VIII. Authorized Official

Name: DR. JEFFREY V DERMKSIAN
Title or Position: TREASURER
Credential: MD
Phone: 212-265-2828