=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902864218
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVERSIDE INTERNAL MEDICINE PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2006
-----------------------------------------------------
Last Update Date | 12/31/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14 ASCUTNEY PLACE UNIT B2
-----------------------------------------------------
City | ASCUTNEY
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-674-6744
-----------------------------------------------------
Fax | 802-674-6744
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 416
-----------------------------------------------------
City | ASCUTNEY
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-674-6744
-----------------------------------------------------
Fax | 802-674-6744
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD OWNER
-----------------------------------------------------
Name | SHEILA J KENDRICK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 802-674-6744
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------