Provider Demographics
NPI:1235149048
Name:MCMAHON & RICKETSON MD PA
Entity Type:Organization
Organization Name:MCMAHON & RICKETSON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:T
Authorized Official - Last Name:STOCKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-476-6110
Mailing Address - Street 1:5147 N 9TH AVE
Mailing Address - Street 2:STE. 203
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8771
Mailing Address - Country:US
Mailing Address - Phone:850-476-6110
Mailing Address - Fax:850-479-6042
Practice Address - Street 1:5147 N 9TH AVE
Practice Address - Street 2:STE. 203
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8771
Practice Address - Country:US
Practice Address - Phone:850-476-6110
Practice Address - Fax:850-479-6042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45688OtherBCBS
AL528302480OtherAL MEDICAID
FL269452200OtherMEDICAID
FLCATALEX3631Medicare PIN
FL45688OtherBCBS