MEDICARE: FREDERICK VIVINO MD

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	207RR0500X	Rheumatology Physician	MD033113E	PA
2	207R00000X	Internal Medicine Physician	MD033113E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952337339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FREDERICK VIVINO MD

Provider Business Mailing Address
First Line	:	3910 N POWELTON AVE
Second Line	:	2ND FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-2640
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3910 N POWELTON AVE
Second Line	:	2ND FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-2640
Country	:	US
Telephone Number	:	215-662-9292
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	11/05/2012

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