Healthcare Provider Details

I. General information

NPI: 1659372605
Provider Name (Legal Business Name): CHRISTOPHER JOHN RIVERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14509 STATE ROUTE 127
CARLYLE IL
62231-6485
US

IV. Provider business mailing address

14509 STATE ROUTE 127
CARLYLE IL
62231-6485
US

V. Phone/Fax

Practice location:
  • Phone: 618-594-3613
  • Fax: 888-859-4347
Mailing address:
  • Phone: 618-594-3613
  • Fax: 888-859-4347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036096480
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036096480
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: