Provider Demographics
NPI:1033144258
Name:RICCIARDI, MARK JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:RICCIARDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CENTRAL ST STE 730
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1779
Mailing Address - Country:US
Mailing Address - Phone:847-846-3278
Mailing Address - Fax:847-676-1727
Practice Address - Street 1:1000 CENTRAL ST STE 730
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1779
Practice Address - Country:US
Practice Address - Phone:847-846-3278
Practice Address - Fax:847-676-1727
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098548207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
G82527Medicare UPIN