Healthcare Provider Details

I. General information

NPI: 1104847854
Provider Name (Legal Business Name): RIVERSIDE PHYSICIAN SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7547 MEDICAL DRIVE SUITE 1500
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: 804-693-3081
  • Fax: 804-693-3283
Mailing address:
  • Phone: 757-594-4006
  • Fax: 757-594-2195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL J DOUCETTE
Title or Position: VICE PRESIDENT
Credential:
Phone: 757-594-4006