Provider Demographics
NPI:1922325026
Name:MODESTO S RIVERA III MD PA
Entity Type:Organization
Organization Name:MODESTO S RIVERA III MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MODESTO
Authorized Official - Middle Name:SANTOS
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:410-535-4242
Mailing Address - Street 1:806 SOLOMONS ISLAND RD N
Mailing Address - Street 2:
Mailing Address - City:PRNC FREDERCK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-3919
Mailing Address - Country:US
Mailing Address - Phone:410-535-3424
Mailing Address - Fax:410-535-4983
Practice Address - Street 1:806 SOLOMONS ISLAND RD N
Practice Address - Street 2:
Practice Address - City:PRNC FREDERCK
Practice Address - State:MD
Practice Address - Zip Code:20678-3919
Practice Address - Country:US
Practice Address - Phone:410-535-3424
Practice Address - Fax:410-535-4983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD19963261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
0283OtherGHMSI
2122218OtherMAMSI
MD1887319 00Medicaid
MD34888001OtherBLUE SHIELD CAREFIRST
MD1887319 00Medicaid