Basic Information
| Provider Information | |||||||||
| NPI: | 1972922664 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIVERSO | ||||||||
| FirstName: | MARISA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191 | ||||||||
| Address2: | |||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197320191 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 APPLIED BANK BLVD STE 11 | ||||||||
| Address2: | |||||||||
| City: | GLEN MILLS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4848008630 | ||||||||
| FaxNumber: | 4848008635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2014 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | C1-0013071 | DE | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208000000X | MD461999 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | C1-0013071 | DE | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | MD461999 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
No ID Information.