Healthcare Provider Details

I. General information

NPI: 1669454104
Provider Name (Legal Business Name): DENNIS W RIVENBURGH PHYSICIAN ASSTISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 10/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5051 GREENSPRING AVE
BALTIMORE MD
21209-4354
US

IV. Provider business mailing address

601 N CAROLINE ST FL 5
BALTIMORE MD
21287-0006
US

V. Phone/Fax

Practice location:
  • Phone: 410-601-9515
  • Fax: 410-601-8905
Mailing address:
  • Phone: 410-955-6825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3490
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA3490
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0004803
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: