Provider Demographics
NPI:1316118276
Name:FERNANDO H. RIVERA M.D. INC
Entity type:Organization
Organization Name:FERNANDO H. RIVERA M.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:H
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-962-1418
Mailing Address - Street 1:3099 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE STATION
Mailing Address - State:IN
Mailing Address - Zip Code:46405-2207
Mailing Address - Country:US
Mailing Address - Phone:219-962-1418
Mailing Address - Fax:219-962-4516
Practice Address - Street 1:3099 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LAKE STATION
Practice Address - State:IN
Practice Address - Zip Code:46405-2207
Practice Address - Country:US
Practice Address - Phone:219-962-1418
Practice Address - Fax:219-962-4516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027425A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN457550Medicare PIN