Provider Demographics
NPI:1093908592
Name:DR. ERNESTO RIVERA MD
Entity Type:Organization
Organization Name:DR. ERNESTO RIVERA MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:D
Authorized Official - Last Name:WHITTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-682-4775
Mailing Address - Street 1:1232 RACE RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-2351
Mailing Address - Country:US
Mailing Address - Phone:410-682-4775
Mailing Address - Fax:410-682-5063
Practice Address - Street 1:1232 RACE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-2351
Practice Address - Country:US
Practice Address - Phone:410-682-4775
Practice Address - Fax:410-682-5063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD18557174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD6774Medicare PIN