Healthcare Provider Details

I. General information

NPI: 1952405367
Provider Name (Legal Business Name): RIVERSIDE TAPPAHANNOCK HOSPITAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 HOSPITAL RD
TAPPAHANNOCK VA
22560-5000
US

IV. Provider business mailing address

606 DENBIGH BLVD SUITE 800
NEWPORT NEWS VA
23608-4413
US

V. Phone/Fax

Practice location:
  • Phone: 804-443-3311
  • Fax: 804-443-6150
Mailing address:
  • Phone: 757-875-7545
  • Fax: 757-875-7553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberH1889
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberH1889
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License NumberH1889
License Number StateVA

VIII. Authorized Official

Name: WADE DUDLEY BROUGHMAN
Title or Position: EXECUTIVE VICE PRESIDENT/CFO
Credential:
Phone: 757-591-7019