Provider Demographics
NPI:1265472211
Name:SIWICKI & RICCIARDI,P.L.
Entity Type:Organization
Organization Name:SIWICKI & RICCIARDI,P.L.
Other - Org Name:EMERALD COAST PODIATRY & WOUND CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:COSIMO
Authorized Official - Middle Name:A
Authorized Official - Last Name:RICCIARDI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:850-862-4119
Mailing Address - Street 1:914A MAR WALT DR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6706
Mailing Address - Country:US
Mailing Address - Phone:850-862-4119
Mailing Address - Fax:
Practice Address - Street 1:341 A RACETRACK RD NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547
Practice Address - Country:US
Practice Address - Phone:850-862-4119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1110 & PO2964213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340598200Medicaid
FLQ0027Medicare PIN
FL5663950001Medicare NSC