MEDICARE: RIVERA MEDICAL OFFICE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	036096480	IL
2	208000000X	Pediatrics Physician	036096480	IL
3	208600000X	Surgery Physician	036045712	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1400038	OTHER	IL	BLUECROSS PROV #

General Provider Information

NPI Number	:	1689883035
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERA MEDICAL OFFICE, LLC

Provider Business Mailing Address
First Line	:	1110 MULLIKEN ST
Second Line	:	PO BOX 147
City	:	CARLYLE
State	:	IL
Zip	:	62231-1233
Country	:	US
Telephone Number	:	618-594-3613
Fax Number	:	618-594-4799

Provider Business Practice Location Address
First Line	:	1110 MULLIKEN ST
Second Line	:
City	:	CARLYLE
State	:	IL
Zip	:	62231-1233
Country	:	US
Telephone Number	:	618-594-3613
Fax Number	:	618-594-4799

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	LISA RIVERA
Credential	:
Telephone Number	:	618-594-3613

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	05/12/2008

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Directions to “RIVERA MEDICAL OFFICE, LLC ” Practice Location

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