Healthcare Provider Details

I. General information

NPI: 1255759429
Provider Name (Legal Business Name): RIVERSIDE PHYSICIAN SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12420 WARWICK BLVD SUITE 4C
NEWPORT NEWS VA
23606-3001
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: 757-596-7115
  • Fax: 757-596-7127
Mailing address:
  • Phone: 757-316-5960
  • Fax: 757-534-5190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: BRADEN MILLER
Title or Position: CFO
Credential:
Phone: 757-316-5900