Basic Information
| Provider Information | |||||||||
| NPI: | 1609257310 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVERSIDE SURGERY CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RIVERSIDE SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3556 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312102509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784262188 | ||||||||
| FaxNumber: | 7708748950 | ||||||||
| Practice Location | |||||||||
| Address1: | 3556 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312102509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784759204 | ||||||||
| FaxNumber: | 4784759572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2015 | ||||||||
| LastUpdateDate: | 07/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | JANA | ||||||||
| AuthorizedOfficialMiddleName: | SUE | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6784262188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.