Healthcare Provider Details

I. General information

NPI: 1114170446
Provider Name (Legal Business Name): RIVERSIDE PHYSICIAN SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2008
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7547 MEDIAL DRIVE SUITE 1300
GLOUCESTER VA
23061
US

IV. Provider business mailing address

856 J CLYDE MORRIS BLVD SUITE A
NEWPORT NEWS VA
23601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 804-695-8550
  • Fax: 804-695-8551
Mailing address:
  • Phone: 757-594-4006
  • Fax: 757-534-5190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateVA

VIII. Authorized Official

Name: BRADEN MILLER
Title or Position: CFO
Credential:
Phone: 757-316-5906