1477500049 NPI number — MARI A RICKER MD

Table of content: MARI A RICKER MD (NPI 1477500049)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477500049 NPI number — MARI A RICKER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RICKER
Provider First Name:
MARI
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALSH
Provider Other First Name:
MARI
Provider Other Middle Name:
ANOUSKA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477500049
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 245052
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85724-5052
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-626-5914
Provider Business Mailing Address Fax Number:
520-626-1640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
707 N ALVERNON WAY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85711-1827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-694-8888
Provider Business Practice Location Address Fax Number:
520-694-1640
Provider Enumeration Date:
05/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD25245 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 023146 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00604911 . This is a "RR MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 49518 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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