Healthcare Provider Details

I. General information

NPI: 1609020643
Provider Name (Legal Business Name): RIVERSIDE PHYSICIAN SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2008
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 WARWICK BLVD STE 490A
NEWPORT NEWS VA
23601-2548
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: 757-534-9988
  • Fax: 757-594-3653
Mailing address:
  • Phone: 757-316-5800
  • Fax: 757-534-5190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

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