Provider Demographics
NPI:1053481903
Name:RICKARD, ORVILLE G (CRNA)
Entity Type:Individual
Prefix:
First Name:ORVILLE
Middle Name:G
Last Name:RICKARD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 E MAGNOLIA LOOP
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:GA
Mailing Address - Zip Code:30650-5069
Mailing Address - Country:US
Mailing Address - Phone:706-752-1444
Mailing Address - Fax:
Practice Address - Street 1:101 GREENSBORO RD
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-6054
Practice Address - Country:US
Practice Address - Phone:706-485-2711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2011-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN045426367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00561756AMedicaid
GA00561756AMedicaid