Basic Information
| Provider Information | |||||||||
| NPI: | 1730106196 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERSIDE FAMILY PRACTICE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 718 TEANECK RD | ||||||||
| Address2: | |||||||||
| City: | TEANECK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076664245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018333000 | ||||||||
| FaxNumber: | 2012276207 | ||||||||
| Practice Location | |||||||||
| Address1: | 718 TEANECK RD | ||||||||
| Address2: | |||||||||
| City: | TEANECK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076664245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018333909 | ||||||||
| FaxNumber: | 2018337073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 05/01/2013 | ||||||||
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| AuthorizedOfficialLastName: | JARRETT | ||||||||
| AuthorizedOfficialFirstName: | ADAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CMO, M.D. | ||||||||
| AuthorizedOfficialTelephone: | 2018333000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25MA03273300 | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 174400000X | 25MA05312800 | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 207QS0010X | 25MA06291500 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 203130405 | 01 | NJ | TAX IDENTIFICATION # | OTHER |