Basic Information
| Provider Information | |||||||||
| NPI: | 1205075470 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | RICKI | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4059 | ||||||||
| Address2: | |||||||||
| City: | WAYNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074744059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738941263 | ||||||||
| FaxNumber: | 8889723703 | ||||||||
| Practice Location | |||||||||
| Address1: | 695 US HIGHWAY 46 | ||||||||
| Address2: | SUITE 400A | ||||||||
| City: | FAIRFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070041592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738268080 | ||||||||
| FaxNumber: | 8663093354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2009 | ||||||||
| LastUpdateDate: | 01/17/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 25MA03589400 | NJ | N | Other Service Providers | Specialist | 208600000X | 25MA03589400 | NJ | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0024155 | 05 | NJ | MEDICAID |