Basic Information
| Provider Information | |||||||||
| NPI: | 1073518064 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICCIARDELLI | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 SHIPYARD BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107945355 | ||||||||
| FaxNumber: | 9107945355 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 SHIPYARD BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107945355 | ||||||||
| FaxNumber: | 9107945358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 12/16/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/21/2006 | ||||||||
| NPIReactivationDate: | 04/03/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 9600699 | NC | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 011E3 | 01 | NC | BLUE CROSS GROUP ID | OTHER | 8971471 | 05 | NC | MEDICAID | 71471 | 01 | NC | BLUE CROSS INDIVIDUAL | OTHER | 1328886 | 01 | NC | UNITED HEALTH CARE | OTHER |