Healthcare Provider Details

I. General information

NPI: 1861416372
Provider Name (Legal Business Name): ROGER KENT RIVES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 03/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 HEALTH CENTER DR SUITE 305
MATTOON IL
61938-9258
US

IV. Provider business mailing address

1005 HEALTH CENTER DR SYSTEM PRACTICES
MATTOON IL
61938-4693
US

V. Phone/Fax

Practice location:
  • Phone: 217-258-4186
  • Fax: 217-258-4185
Mailing address:
  • Phone: 217-258-2576
  • Fax: 217-258-4175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036061773
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: