Provider Demographics
NPI:1205845443
Name:RICCIUTI, ALEX (MD)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:RICCIUTI
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 1:34 BROOKLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-3802
Mailing Address - Country:US
Mailing Address - Phone:610-449-9838
Mailing Address - Fax:
Practice Address - Street 1:34 BROOKLINE BLVD
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-3802
Practice Address - Country:US
Practice Address - Phone:610-449-9838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD050842L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA708451OtherHIGHMARK
PA065101Medicare ID - Type UnspecifiedMEDICARE