Provider Demographics
NPI:1700096963
Name:RIVERA, SIMON
Entity Type:Individual
Prefix:MR
First Name:SIMON
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38935 ANN ARBOR ROAD
Mailing Address - Street 2:CREDENTIALING/PAYER CONTRACTING
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3397
Mailing Address - Country:US
Mailing Address - Phone:734-805-0477
Mailing Address - Fax:866-250-6385
Practice Address - Street 1:13700 ST. FRANCIS BLVD
Practice Address - Street 2:EMERGENCY MEDICINE DEPARTMENT
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-3267
Practice Address - Country:US
Practice Address - Phone:804-594-7950
Practice Address - Fax:804-594-0489
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011817363A00000X
VA0110002952363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAPENDINGMedicare PIN