Provider Demographics
NPI:1023372448
Name:RICKY D ST ONGE, MD LLC
Entity Type:Organization
Organization Name:RICKY D ST ONGE, MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:ST ONGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-645-3893
Mailing Address - Street 1:1255 N HAMILTON RD # 216
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-6785
Mailing Address - Country:US
Mailing Address - Phone:740-645-3893
Mailing Address - Fax:
Practice Address - Street 1:5910 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-6881
Practice Address - Country:US
Practice Address - Phone:614-882-4343
Practice Address - Fax:614-882-4664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-29
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-066328261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty