Healthcare Provider Details

I. General information

NPI: 1972989713
Provider Name (Legal Business Name): RIVERVIEW MEDICAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2015
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10732 KETCHUM VALLEY DR
RIVERVIEW FL
33579-7185
US

IV. Provider business mailing address

10732 KETCHUM VALLEY DR
RIVERVIEW FL
33579-7185
US

V. Phone/Fax

Practice location:
  • Phone: 813-677-2700
  • Fax: 813-677-6355
Mailing address:
  • Phone: 813-677-2700
  • Fax: 813-677-6355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME54579
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA91008766
License Number StateFL

VIII. Authorized Official

Name: STEVEN JOSEPH MINAFRI
Title or Position: PRESIDENT
Credential:
Phone: 813-677-2700