Provider Demographics
NPI:1154432623
Name:RIVERS, MARIA BLACK (MD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:BLACK
Last Name:RIVERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARIA
Other - Middle Name:MYERS
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3524 LAKESTONE CT
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-8977
Mailing Address - Country:US
Mailing Address - Phone:706-854-0883
Mailing Address - Fax:
Practice Address - Street 1:1 FREEDOM WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6258
Practice Address - Country:US
Practice Address - Phone:706-823-2216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA23907207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD39421Medicare UPIN