Provider Demographics
NPI:1902833429
Name:RIVLIN, MICHEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHEL
Middle Name:
Last Name:RIVLIN
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5373
Mailing Address - Fax:601-984-5476
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5373
Practice Address - Fax:601-984-5476
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS8037207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512G700003OtherUP MEDICARE GROUP PROV#
MS512I160014OtherMEDICARE PTAN
MSP00616899OtherUP RR MEDICARE PTAN#
MS00016020Medicaid
MS08103071OtherUP MEDICAID GROUP PROV#
MS160039244OtherRR MEDICARE NUMBER
MS160039244OtherRR MEDICARE NUMBER
MSC00319Medicare ID - Type UnspecifiedMCRE GROUP PROV NUMBER
MS302I167003Medicare PIN
MSP00616899OtherUP RR MEDICARE PTAN#