Provider Demographics
NPI:1669454104
Name:RIVENBURGH, DENNIS W (PHYSICIAN ASSTISTANT)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:W
Last Name:RIVENBURGH
Suffix:
Gender:M
Credentials:PHYSICIAN ASSTISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N CAROLINE ST FL 5
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287-0006
Mailing Address - Country:US
Mailing Address - Phone:410-955-6825
Mailing Address - Fax:
Practice Address - Street 1:5051 GREENSPRING AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-4354
Practice Address - Country:US
Practice Address - Phone:410-601-9515
Practice Address - Fax:410-601-8905
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3490363A00000X, 363AS0400X
MDC0004803363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290365200Medicaid
970005415OtherRAILROAD MEDICARE
FLS84151Medicare UPIN
FLE2761WMedicare PIN