Provider Demographics
NPI:1154542686
Name:RIVERA-KOLB, JORGE E (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:E
Last Name:RIVERA-KOLB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 MEADOW SPRINGS DR SW
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5768
Mailing Address - Country:US
Mailing Address - Phone:770-648-6207
Mailing Address - Fax:
Practice Address - Street 1:1008 MEADOW SPRINGS DR SW
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5768
Practice Address - Country:US
Practice Address - Phone:770-648-6207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA28360207PH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAC82693Medicare UPIN