Organization
RIVERA MEDICAL OFFICE, LLC
Active
Other names
Renato B. Rivera, MD, LLC
Organization subpart
No
Provider details
NPI number
Authorized official
LISA RIVERA (OFFICE MANAGER)
(618) 594-3613
Entity
Organization
Contact information
Practice address
1110 MULLIKEN ST, CARLYLE, IL 62231-1233
(618) 594-3613
(618) 594-4799
Mailing address
1110 MULLIKEN ST, PO BOX 147, CARLYLE, IL 62231-1233
(618) 594-3613
(618) 594-4799
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
036096480
IL
208000000X
Pediatrics Physician
036096480
IL
208600000X
Surgery Physician
Primary
036045712
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1400038
BLUECROSS PROV #
IL
Enumeration date
05/22/2007
Last updated
05/12/2008
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