Healthcare Provider Details

I. General information

NPI: 1982758041
Provider Name (Legal Business Name): SAMUEL RIVERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 WARREN ST
ROXBURY MA
02119-1833
US

IV. Provider business mailing address

30 UNION SQ
RANDOLPH MA
02368-4852
US

V. Phone/Fax

Practice location:
  • Phone: 617-442-7400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number57247
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: