Provider Demographics
NPI:1184019671
Name:LARIVIERE, MICHAEL JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:LARIVIERE
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 1:3400 CIVIC CENTER BLVD
Mailing Address - Street 2:PCAM-2 WEST
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5127
Mailing Address - Country:US
Mailing Address - Phone:215-615-7239
Mailing Address - Fax:
Practice Address - Street 1:3400 CIVIC CENTER BLVD
Practice Address - Street 2:PCAM-2 WEST
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5127
Practice Address - Country:US
Practice Address - Phone:215-615-7239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4714272085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology