Provider Demographics
NPI:1144231291
Name:COLLIS, RICKY STANLEY (MD)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:STANLEY
Last Name:COLLIS
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 1:315 E BROADWAY
Mailing Address - Street 2:SUITE 250
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3700
Mailing Address - Country:US
Mailing Address - Phone:502-589-4765
Mailing Address - Fax:502-589-4799
Practice Address - Street 1:315 E BROADWAY
Practice Address - Street 2:SUITE 250
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3700
Practice Address - Country:US
Practice Address - Phone:502-589-4765
Practice Address - Fax:502-589-4799
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29814208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0005382490OtherAETNA
000000043722OtherANTHEM
IN200137520AMedicaid
KY64298144Medicaid
KY1058769Medicaid
G42572Medicare UPIN
KY0621501Medicare PIN
KY1058769Medicaid
2434019000Medicare NSC
IN187540AMedicare PIN