Healthcare Provider Details

I. General information

NPI: 1134303928
Provider Name (Legal Business Name): RIVERSIDE PHYSICIAN SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 KINGS WAY STE 3500
WILLIAMSBURG VA
23185-2511
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: 757-253-0051
  • Fax: 757-229-9526
Mailing address:
  • Phone: 757-594-4006
  • Fax: 757-534-5190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: BILLIE JO BROWN
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 757-316-5901