Provider Demographics
NPI:1083940464
Name:REIVICH, MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:REIVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 HAMILTON WALK
Mailing Address - Street 2:415 STEMMLER HALL
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-6118
Mailing Address - Country:US
Mailing Address - Phone:215-662-2632
Mailing Address - Fax:215-349-5629
Practice Address - Street 1:3450 HAMILTON WALK
Practice Address - Street 2:415 STEMMLER HALL
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-6118
Practice Address - Country:US
Practice Address - Phone:215-662-2632
Practice Address - Fax:215-349-5629
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD005708E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine