MEDICARE: RIVERVIEW MEDICAL, INC

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	363AM0700X	Medical Physician Assistant	PA91008766	FL
2	207R00000X	Internal Medicine Physician	ME54579	FL

General Provider Information

NPI Number	:	1972989713
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERVIEW MEDICAL, INC

Provider Business Mailing Address
First Line	:	10732 KETCHUM VALLEY DR
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33579-7185
Country	:	US
Telephone Number	:	813-677-2700
Fax Number	:	813-677-6355

Provider Business Practice Location Address
First Line	:	10732 KETCHUM VALLEY DR
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33579-7185
Country	:	US
Telephone Number	:	813-677-2700
Fax Number	:	813-677-6355

Authorized Official
Title or Position	:	PRESIDENT
Name	:	STEVEN JOSEPH MINAFRI
Credential	:
Telephone Number	:	813-677-2700

Provider Enumeration Date	:	08/04/2015
Last Update Date	:	05/24/2016

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