Basic Information
| Provider Information | |||||||||
| NPI: | 1801881016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KINZEY | ||||||||
| FirstName: | RICKEY | ||||||||
| MiddleName: | DALE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 MARKET ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTOWN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471119535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125035100 | ||||||||
| FaxNumber: | 7705739513 | ||||||||
| Practice Location | |||||||||
| Address1: | 1802 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | JEFFERSONVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471306016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122882488 | ||||||||
| FaxNumber: | 7705739513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 10/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0401X | 02000860A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine | 207L00000X | T1985 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 02000860A | IN | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100446040 | 05 | IN | MEDICAID | 000000368845 | 01 | IN | RKP ANTHEM | OTHER | 000000368855 | 01 | IN | RKA ANTHEM | OTHER |