1023078623 NPI number — SHANNELLE SUSANNE RICO MD

Table of content: SHANNELLE SUSANNE RICO MD (NPI 1023078623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023078623 NPI number — SHANNELLE SUSANNE RICO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RICO
Provider First Name:
SHANNELLE
Provider Middle Name:
SUSANNE
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:
RICO
Provider Other First Name:
SHANNELLE
Provider Other Middle Name:
SUSANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1023078623
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
HWY 77/75
Provider Second Line Business Mailing Address:
P.O. BOX HH
Provider Business Mailing Address City Name:
WINNEBAGO
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68071-0767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-878-2231
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ROSEBUD IHS HOSPITAL
Provider Second Line Business Practice Location Address:
SOLDIER CREEK ROAD
Provider Business Practice Location Address City Name:
ROSEBUD
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57570-0400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-747-3245
Provider Business Practice Location Address Fax Number:
605-747-2216
Provider Enumeration Date:
03/27/2006

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:  01050363A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000378568 . This is a "BLUE CROSS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200381310 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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