1720083702 NPI number — ROBERTO A. LARRIVEY MD

Table of content: ROBERTO A. LARRIVEY MD (NPI 1720083702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720083702 NPI number — ROBERTO A. LARRIVEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARRIVEY
Provider First Name:
ROBERTO
Provider Middle Name:
A.
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:
1720083702
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5555 PEACHTREE DUNWOODY RD NE
Provider Second Line Business Mailing Address:
STE 125
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30342-1703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-255-2918
Provider Business Mailing Address Fax Number:
404-255-5837

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
790 CHURCH ST NE
Provider Second Line Business Practice Location Address:
STE 140
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30060-8902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-425-7199
Provider Business Practice Location Address Fax Number:
678-819-5538
Provider Enumeration Date:
06/16/2005

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: 207Y00000X , with the licence number:  052983 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 956323850A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 956323850B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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