Basic Information
Provider Information | |||||||||
NPI: | 1619178621 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RACKLEY | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1735 27TH ST STE B06 | ||||||||
Address2: |   | ||||||||
City: | PORTSMOUTH | ||||||||
State: | OH | ||||||||
PostalCode: | 456622681 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403568681 | ||||||||
FaxNumber: | 7403537900 | ||||||||
Practice Location | |||||||||
Address1: | 1711 27TH ST STE 103A | ||||||||
Address2: |   | ||||||||
City: | PORTSMOUTH | ||||||||
State: | OH | ||||||||
PostalCode: | 456622654 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403566740 | ||||||||
FaxNumber: | 7403559281 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/29/2007 | ||||||||
LastUpdateDate: | 12/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 35.090802 | OH | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0600X | 35-090802 | OH | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
ID Information
ID | Type | State | Issuer | Description | 2800508 | 05 | OH |   | MEDICAID | 7100179190 | 05 | KY |   | MEDICAID | P00981133 | 01 | KY | RAILROAD MEDICARE | OTHER |