1184053423 NPI number — MRS. REBECCA RIVERA PA-C

Table of content: MRS. REBECCA RIVERA PA-C (NPI 1184053423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184053423 NPI number — MRS. REBECCA RIVERA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA
Provider First Name:
REBECCA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BIBB
Provider Other First Name:
REBECCA
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184053423
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2700 STANLEY GAULT PKWY STE 129
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40223-5176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-253-4917
Provider Business Mailing Address Fax Number:
502-487-5751

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7725 HIGHWAY 62 STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTOWN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-280-0413
Provider Business Practice Location Address Fax Number:
812-280-0465
Provider Enumeration Date:
11/07/2013

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: 363A00000X , with the licence number:  10001839A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300007796 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: IN1189154 . This is a "IN MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: PA08679 . This is a "TEXAS MEDICAL BOARD PA LICENSE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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