=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467242834
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARCOS ELI RIVERA NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2025
-----------------------------------------------------
Last Update Date | 07/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26 CITY HALL MALL
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02155-4754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-306-5100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 290 MISHAWUM RD UNIT 4047
-----------------------------------------------------
City | WOBURN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01801-2275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-478-5786
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN2390102
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | RN2390102
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------