Basic Information
Provider Information | |||||||||
NPI: | 1902832165 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RIVERS | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 601 ELMWOOD AVE | ||||||||
Address2: | BOX 629 | ||||||||
City: | ROCHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 146420001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5857585700 | ||||||||
FaxNumber: | 5857581293 | ||||||||
Practice Location | |||||||||
Address1: | 2365 CLINTON AVE S | ||||||||
Address2: | SUITE 200 | ||||||||
City: | ROCHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 146182645 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5857585700 | ||||||||
FaxNumber: | 5857581293 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/22/2006 | ||||||||
LastUpdateDate: | 03/17/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WX0601X | F330916 | NY | Y |   | Nursing Service Providers | Registered Nurse | Otorhinolaryngology & Head-Neck |
ID Information
ID | Type | State | Issuer | Description | P019330916 | 01 | NY | BLUE CHOICE | OTHER | 02430495 | 05 | NY |   | MEDICAID | CW109237 | 01 | NY | PREFERRED CARE | OTHER |