Healthcare Provider Details

I. General information

NPI: 1982933842
Provider Name (Legal Business Name): RIVERSIDE GYN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2009
Last Update Date: 12/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5777 KELLOGG AVE
CINCINNATI OH
45230-7142
US

IV. Provider business mailing address

5777 KELLOGG AVENUE
CINCINNATI OH
45230
US

V. Phone/Fax

Practice location:
  • Phone: 513-232-3232
  • Fax: 513-333-3024
Mailing address:
  • Phone: 513-232-3232
  • Fax: 513-232-3202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberOH048288
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number35058827
License Number StateOH

VIII. Authorized Official

Name: TARI S ANDERSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 513-232-3232