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	207R00000X	Internal Medicine Physician
2	208800000X	Urology Physician

General Provider Information

NPI Number	:	1093736605
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	:	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

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

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	01/13/2015

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