Provider Demographics
NPI:1154314979
Name:SPOTTS, RICKE L (MD)
Entity Type:Individual
Prefix:
First Name:RICKE
Middle Name:L
Last Name:SPOTTS
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 1:717 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-6721
Mailing Address - Country:US
Mailing Address - Phone:717-274-6657
Mailing Address - Fax:717-270-6615
Practice Address - Street 1:717 S 8TH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-6721
Practice Address - Country:US
Practice Address - Phone:717-274-6657
Practice Address - Fax:717-270-6615
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD019767E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA091490OtherHIGHMARK BLUE SHIELD
PA03182300OtherCAPITAL BLUE CROSS
PA0006877850006Medicaid
PA0006877850006Medicaid
PA091490OtherHIGHMARK BLUE SHIELD