1396863924 NPI number — DR. STEPHEN P RIVERA M.D.

Table of content: DR. STEPHEN P RIVERA M.D. (NPI 1396863924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396863924 NPI number — DR. STEPHEN P RIVERA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA
Provider First Name:
STEPHEN
Provider Middle Name:
P
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RIVERA, LTD
Provider Other First Name:
STEPHEN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1396863924
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 MIDDLETREE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAWTHORN WOODS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60047-8993
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
224-286-7318
Provider Business Mailing Address Fax Number:
847-381-0301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 MIDDLETREE LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAWTHORN WOODS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
224-286-7318
Provider Business Practice Location Address Fax Number:
847-381-0301
Provider Enumeration Date:
03/26/2007

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: 2084P0800X , with the licence number:  036089771 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001620065 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 260050348 . This is a "PALMETTO GBA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036089771 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".