Provider Demographics
NPI:1235296591
Name:RICKERT, KIM L (MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:L
Last Name:RICKERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-887-2839
Practice Address - Fax:570-887-3122
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI43836-020207T00000X
TX7571207T00000X
TXM7571207T00000X
PAMD455464207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery