Basic Information
| Provider Information | |||||||||
| NPI: | 1578777439 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIVERA | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 301 LIPPINCOTT DR STE 410 | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080534197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563550340 | ||||||||
| FaxNumber: | 8563550330 | ||||||||
| Practice Location | |||||||||
| Address1: | 218A SUNSET RD | ||||||||
| Address2: | |||||||||
| City: | WILLINGBORO | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080461110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098353056 | ||||||||
| FaxNumber: | 6098353061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 11/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 249580 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 25MA08177400 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 25MA08177400 | NJ | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 03014326 | 05 | NY | MEDICAID | 0155578 | 05 | NJ | MEDICAID | P01069999 | 01 | NJ | RAILROAD MEDICARE | OTHER |