1366410276 NPI number — EMILIO T. RIVERA MD

Table of content: EMILIO T. RIVERA MD (NPI 1366410276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366410276 NPI number — EMILIO T. RIVERA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA
Provider First Name:
EMILIO
Provider Middle Name:
T.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366410276
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1590
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA TERESA
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88008-1590
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-589-1144
Provider Business Mailing Address Fax Number:
575-589-2008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5290 MCNUTT RD
Provider Second Line Business Practice Location Address:
STE 109
Provider Business Practice Location Address City Name:
SANTA TERESA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-589-1144
Provider Business Practice Location Address Fax Number:
575-589-2008
Provider Enumeration Date:
03/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  89-285 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 89-285 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 050051043 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: NM009D02 . This is a "BCBS OF NM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM011595 . This is a "BCBS NM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 30858 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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