Provider Demographics
NPI:1518143254
Name:JAMES J. DALLA RIVA, MD, PC
Entity Type:Organization
Organization Name:JAMES J. DALLA RIVA, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:DALLA RIVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-288-5699
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360879061Medicaid
ILF74946Medicare UPIN
IL339140Medicare PIN