MEDICARE: RIVERSIDE PHYSICIAN SERVICES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician		VA

General Provider Information

NPI Number	:	1083867691
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERSIDE PHYSICIAN SERVICES INC

Provider Business Mailing Address
First Line	:	856 J CLYDE MORRIS BLVD
Second Line	:	SUITE A
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23601-1318
Country	:	US
Telephone Number	:	757-594-4006
Fax Number	:	757-534-5190

Provider Business Practice Location Address
First Line	:	739 THIMBLE SHOALS BLVD
Second Line	:	SUITE 801
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23606-3562
Country	:	US
Telephone Number	:	757-873-1009
Fax Number	:	757-873-7689

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	JAMES LESNICK
Credential	:	MD
Telephone Number	:	757-594-4006

Provider Enumeration Date	:	10/28/2008
Last Update Date	:	10/14/2014

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