Provider Demographics
NPI:1982758041
Name:RIVERS, SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:RIVERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 UNION SQ
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-4852
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:435 WARREN ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-1833
Practice Address - Country:US
Practice Address - Phone:617-442-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57247174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAG23105Medicare UPIN