Provider Demographics
NPI:1215040415
Name:DALLA RIVA, JAMES JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:JOSEPH
Last Name:DALLA RIVA
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 1:6810 STATE ROUTE 162
Mailing Address - Street 2:SUITE 301
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8501
Mailing Address - Country:US
Mailing Address - Phone:618-288-5699
Mailing Address - Fax:618-288-5797
Practice Address - Street 1:6810 STATE ROUTE 162
Practice Address - Street 2:SUITE 301
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8501
Practice Address - Country:US
Practice Address - Phone:618-288-5699
Practice Address - Fax:618-288-5797
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360879061Medicaid
339140Medicare ID - Type Unspecified
IL0360879061Medicaid