Provider Demographics
NPI:1669582649
Name:RIVNER, MICHAEL H (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:H
Last Name:RIVNER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3351 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2587
Mailing Address - Country:US
Mailing Address - Phone:478-201-6629
Mailing Address - Fax:
Practice Address - Street 1:4035 ELNORA DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1822
Practice Address - Country:US
Practice Address - Phone:478-731-4095
Practice Address - Fax:478-633-5261
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0208062084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN20806Medicaid
GA000263997AMedicaid
D30633Medicare UPIN