Basic Information
| Provider Information | |||||||||
| NPI: | 1760569644 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICCELLI | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RICCELLI | ||||||||
| OtherFirstName: | LECIA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | WIFE | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4560 BECKER RD | ||||||||
| Address2: | |||||||||
| City: | BREWERTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130298700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3156763169 | ||||||||
| FaxNumber: | 3156762574 | ||||||||
| Practice Location | |||||||||
| Address1: | 5100 W TAFT RD | ||||||||
| Address2: | |||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130883807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154522200 | ||||||||
| FaxNumber: | 3154522204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 1541 | NY | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.