Provider Demographics
NPI:1073518064
Name:RICCIARDELLI, EDWARD JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JOSEPH
Last Name:RICCIARDELLI
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 1:1717 SHIPYARD BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403
Mailing Address - Country:US
Mailing Address - Phone:910-794-5355
Mailing Address - Fax:910-794-5355
Practice Address - Street 1:1717 SHIPYARD BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403
Practice Address - Country:US
Practice Address - Phone:910-794-5355
Practice Address - Fax:910-794-5358
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2010-12-16
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
NC9600699208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC011E3OtherBLUE CROSS GROUP ID
NC8971471Medicaid
NC71471OtherBLUE CROSS INDIVIDUAL
NC1328886OtherUNITED HEALTH CARE
NC1328886OtherUNITED HEALTH CARE
NC2344578Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
NCF68078Medicare UPIN