Basic Information
| Provider Information | |||||||||
| NPI: | 1740276203 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERSIDE ASSOCIATES IN ANESTHESIA PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38-40 FRONT ST | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139054712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077227264 | ||||||||
| FaxNumber: | 6077227869 | ||||||||
| Practice Location | |||||||||
| Address1: | OUR LADY OF LOURDES HOSPITAL | ||||||||
| Address2: | 169 RIVERSIDE DRIVE | ||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139054246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077227264 | ||||||||
| FaxNumber: | 6077227869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MONTEITH | ||||||||
| AuthorizedOfficialFirstName: | W. | ||||||||
| AuthorizedOfficialMiddleName: | KENT | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6077227264 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00467469 | 05 | NY | MEDICAID | 1130615082 | 01 | TRAVELERS MEDICARE | OTHER | 0912726 | 05 | PA | MEDICAID |