Provider Demographics
NPI:1033231600
Name:ROBERT J RICCHETTI MD
Entity Type:Organization
Organization Name:ROBERT J RICCHETTI MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:RICCHETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-624-7333
Mailing Address - Street 1:9140 ACADEMY ROAD
Mailing Address - Street 2:SUITE G
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114
Mailing Address - Country:US
Mailing Address - Phone:215-624-7333
Mailing Address - Fax:215-624-7955
Practice Address - Street 1:9140 ACADEMY ROAD
Practice Address - Street 2:SUITE G
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114
Practice Address - Country:US
Practice Address - Phone:215-624-7333
Practice Address - Fax:215-624-7955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD023106-E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2816685001OtherKEYSTONE
PA2816685000OtherBLUE SHIELD
PA2816685000OtherBLUE SHIELD