Provider Demographics
NPI:1467569632
Name:RIVERS, STACIA A (MD)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:A
Last Name:RIVERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MS21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:651-523-9800
Mailing Address - Fax:
Practice Address - Street 1:2165 WHITE BEAR AVE - MAIL STOP 31600A
Practice Address - Street 2:HEALTHPARTNERS MAPLEWOOD CLINIC
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109
Practice Address - Country:US
Practice Address - Phone:651-523-9800
Practice Address - Fax:651-523-9801
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46839208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0450916Medicaid
IA0450916Medicaid
IAI16328Medicare ID - Type Unspecified