Provider Demographics
NPI:1972922664
Name:RIVERSO, MARISA (MD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:RIVERSO
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:PO BOX 191
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 APPLIED BANK BLVD STE 11
Practice Address - Street 2:
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342
Practice Address - Country:US
Practice Address - Phone:484-800-8630
Practice Address - Fax:484-800-8635
Is Sole Proprietor?:No
Enumeration Date:2014-04-10
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0013071207P00000X, 208000000X
PAMD461999208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics