MEDICARE: RIVERSIDE SPINE & PAIN PHYSICIANS, LLC

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	ME83572	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2947648	OTHER	FL	AETNA
2	34167	OTHER	FL	BLUE CROSS BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639208648
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERSIDE SPINE & PAIN PHYSICIANS, LLC

Provider Business Mailing Address
First Line	:	7207 GOLDEN WINGS RD STE 100
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32244-3324
Country	:	US
Telephone Number	:	904-389-1010
Fax Number	:	904-389-1082

Provider Business Practice Location Address
First Line	:	7207 GOLDEN WINGS RD STE 100
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32244-3324
Country	:	US
Telephone Number	:	904-389-1010
Fax Number	:	904-389-1082

Authorized Official
Title or Position	:	OFFICER AND AUTHORIZED OFFICIAL
Name	:	DR. JENNIFER B BALDOCK
Credential	:
Telephone Number	:	615-234-5900

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	07/14/2022

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