Basic Information
| Provider Information | |||||||||
| NPI: | 1225576077 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVERSIDE PEDIATRIC GROUP, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RIVERSIDE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HARMON PLZ FL 10 | ||||||||
| Address2: | |||||||||
| City: | SECAUCUS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070942803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2016367233 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 540 37TH ST | ||||||||
| Address2: | |||||||||
| City: | UNION CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070872545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018646860 | ||||||||
| FaxNumber: | 2013921596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2017 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRAHMBHATT | ||||||||
| AuthorizedOfficialFirstName: | GAURANG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 2016367233 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.