MEDICARE: MR. JOSHUA KARL RIVERA ATC

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	2255A2300X	Athletic Trainer	RT003607	PA

General Provider Information

NPI Number	:	1881902013
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSHUA KARL RIVERA ATC

Provider Business Mailing Address
First Line	:	1495 SYCAMORE AVE
Second Line	:
City	:	WILLOW GROVE
State	:	PA
Zip	:	19090-1019
Country	:	US
Telephone Number	:	267-315-0934
Fax Number	:	215-427-2433

Provider Business Practice Location Address
First Line	:	3300 ARAMINGO AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19134-4500
Country	:	US
Telephone Number	:	215-427-2242
Fax Number	:	215-427-2433

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2010
Last Update Date	:	09/22/2010

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