1689650905 NPI number — MR. RICKY LEE SEDGWICK DO

Table of content: MR. RICKY LEE SEDGWICK DO (NPI 1689650905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689650905 NPI number — MR. RICKY LEE SEDGWICK DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEDGWICK
Provider First Name:
RICKY
Provider Middle Name:
LEE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1689650905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2441
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVENPORT
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52809-2441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-324-8160
Provider Business Mailing Address Fax Number:
563-324-8486

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1227 EAST RUSHOLME STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVENPORT
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52803-2498
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-421-1000
Provider Business Practice Location Address Fax Number:
563-421-7889
Provider Enumeration Date:
12/19/2005

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: 207L00000X , with the licence number:  02932 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6125393 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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