MEDICARE: RIVERSIDE NEUROLOGY 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	174400000X	Specialist	A44002	CA
2	174400000X	Specialist

General Provider Information

NPI Number	:	1508059007
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERSIDE NEUROLOGY INC

Provider Business Mailing Address
First Line	:	7172 MAGNOLIA AVE
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92504-3804
Country	:	US
Telephone Number	:	951-788-2224
Fax Number	:	951-788-5190

Provider Business Practice Location Address
First Line	:	7172 MAGNOLIA AVE
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92504-3804
Country	:	US
Telephone Number	:	951-788-2224
Fax Number	:	951-788-5190

Authorized Official
Title or Position	:	M.D.
Name	:	MR. WASEEM N IBRAHIM
Credential	:	M.D.
Telephone Number	:	951-788-2224

Provider Enumeration Date	:	08/20/2007
Last Update Date	:	01/24/2014

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Directions to “RIVERSIDE NEUROLOGY INC ” Practice Location

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