Provider Demographics
NPI:1396863924
Name:RIVERA, STEPHEN P (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:P
Last Name:RIVERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:STEPHEN
Other - Middle Name:
Other - Last Name:RIVERA, LTD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5 MIDDLETREE LN
Mailing Address - Street 2:
Mailing Address - City:HAWTHORN WOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60047-8993
Mailing Address - Country:US
Mailing Address - Phone:224-286-7318
Mailing Address - Fax:847-381-0301
Practice Address - Street 1:5 MIDDLETREE LANE
Practice Address - Street 2:
Practice Address - City:HAWTHORN WOODS
Practice Address - State:IL
Practice Address - Zip Code:60047
Practice Address - Country:US
Practice Address - Phone:224-286-7318
Practice Address - Fax:847-381-0301
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360897712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL001620065OtherBCBS
IL260050348OtherPALMETTO GBA
IL036089771Medicaid
IL301090Medicare ID - Type UnspecifiedMEDICARE B
IL260050348OtherPALMETTO GBA