1295768851 NPI number — ROBERT M. RICKETTS, MD, PA

Table of content: (NPI 1295768851)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295768851 NPI number — ROBERT M. RICKETTS, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERT M. RICKETTS, MD, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295768851
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
910 WASHINGTON RD
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
WESTMINSTER
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21157-5827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-876-9111
Provider Business Mailing Address Fax Number:
410-857-3345

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 WASHINGTON RD
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
WESTMINSTER
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21157-5827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-876-9111
Provider Business Practice Location Address Fax Number:
410-857-3345
Provider Enumeration Date:
07/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RICKETTS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
MASON
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
410-876-9111

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  D0039296 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 629050 . This is a "MAMSI/UHC PROVIDER#" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 2534363 . This is a "AETNA PROV #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 2500754 . This is a "UHC PROVIDER#" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 596ARO . This is a "BC & BS MEMBER #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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