Provider Demographics
NPI:1265470934
Name:RICKABAUGH, COLEEN A (MD)
Entity Type:Individual
Prefix:
First Name:COLEEN
Middle Name:A
Last Name:RICKABAUGH
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 888
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22404
Mailing Address - Country:US
Mailing Address - Phone:800-888-1752
Mailing Address - Fax:616-975-9824
Practice Address - Street 1:1001 SAM PERRY BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401
Practice Address - Country:US
Practice Address - Phone:540-741-1167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101058419207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00123376OtherRAILROAD MEDICARE
00V866F01Medicare PIN
G08487Medicare UPIN