Healthcare Provider Details

I. General information

NPI: 1427229178
Provider Name (Legal Business Name): RIVERSIDE PHYSICIAN SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 BULIFANTS BLVD SUITE B
WILLIAMSBURG VA
23188-5712
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: 757-259-9540
  • Fax: 757-259-9547
Mailing address:
  • Phone: 757-594-4006
  • Fax: 757-534-5190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number0101232846
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0101232846
License Number StateVA

VIII. Authorized Official

Name: JAMES LESNICK
Title or Position: VICE PRESIDENT
Credential: MD
Phone: 757-594-4006