Provider Demographics
NPI:1164476180
Name:RICKER, BEVERLY J (MD)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:J
Last Name:RICKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-3923
Mailing Address - Country:US
Mailing Address - Phone:429-075-9853
Mailing Address - Fax:
Practice Address - Street 1:5300 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241
Practice Address - Country:US
Practice Address - Phone:429-075-9853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9937208000000X
WI33359208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND25404OtherNDBS #
WI32019300Medicaid
ND40858OtherLHS/BANNERHEALTH #
ND1203228OtherMEDICA #
ND13381Medicaid
ND647218400Medicaid
ND972S1RIOtherMNBS #
NDDA9061008851OtherPREFERRED ONE #
ND972S3RIOtherMNBS #
ND972S2RIOtherMNBS #
ND24202OtherAMERICA'S PPO/ARAZ #
ND972S0RIOtherMNBS #
ND108971OtherUCARE #
ND1203229OtherMEDICA #
ND25406OtherNDBS #
ND1203226OtherMEDICA #
ND1203227OtherMEDICA #
ND972S3RIOtherMNBS #