MEDICARE: RIVA MEDICAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	D40733	MD

General Provider Information

NPI Number	:	1780744318
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVA MEDICAL, LLC

Provider Business Mailing Address
First Line	:	3169 BRAVERTON ST
Second Line	:	SUITE 102
City	:	EDGEWATER
State	:	MD
Zip	:	21037-2679
Country	:	US
Telephone Number	:	410-956-9566
Fax Number	:	443-716-2595

Provider Business Practice Location Address
First Line	:	3169 BRAVERTON ST
Second Line	:	SUITE 102
City	:	EDGEWATER
State	:	MD
Zip	:	21037-2679
Country	:	US
Telephone Number	:	410-956-9566
Fax Number	:	443-716-2595

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WHAY HAN JONES
Credential	:	MD
Telephone Number	:	410-956-9566

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	08/22/2020

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