Provider Demographics
NPI:1225100134
Name:RICKEY, COLLEEN MOLLOY (MD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MOLLOY
Last Name:RICKEY
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8800 N TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3300
Practice Address - Country:US
Practice Address - Phone:704-863-6241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-00979208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901034Medicaid
SCN0097IMedicaid
NC2041546Medicare PIN
SCN0097IMedicaid
NC2041546AMedicare PIN