Basic Information
| Provider Information | |||||||||
| NPI: | 1902810369 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICKLER | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 345 BLACKSTONE BLVD | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029064800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014556200 | ||||||||
| FaxNumber: | 4014556309 | ||||||||
| Practice Location | |||||||||
| Address1: | 345 BLACKSTONE BLVD | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029064800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014556200 | ||||||||
| FaxNumber: | 4014556309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 05/20/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD08987 | RI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 25226-5 | 01 | RI | BLUE CROSS | OTHER | 1104801349 | 01 | RI | BUTLER HOSPITAL NPI | OTHER | 204792 | 01 | RI | BLUE CHIP | OTHER | 05-00163 | 01 | RI | UNITED HEALTHCARE | OTHER | 9025246 | 05 | RI | MEDICAID | 1093831646 | 01 | RI | BUTLER HOSPITAL PROFESSIONAL BILLING OFFICE | OTHER |