Provider Demographics
NPI:1285999490
Name:RIVA AESTHETIC DERMATOLOGY, PLLC
Entity type:Organization
Organization Name:RIVA AESTHETIC DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:SHAFRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-607-1518
Mailing Address - Street 1:17039 KENTON DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-5775
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17039 KENTON DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-5775
Practice Address - Country:US
Practice Address - Phone:704-607-1518
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39997174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E86282Medicare UPIN