Provider Demographics
NPI:1235173048
Name:RIVERA, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:RIVERA
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:PO BOX 2047
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29622-2047
Mailing Address - Country:US
Mailing Address - Phone:864-261-3999
Mailing Address - Fax:864-224-8379
Practice Address - Street 1:1519 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-4707
Practice Address - Country:US
Practice Address - Phone:864-261-3999
Practice Address - Fax:864-224-8379
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8701207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC087015Medicaid
D99419Medicare UPIN
SC087015Medicaid