Provider Demographics
NPI:1275543191
Name:RICCI, CARRIE ANN-BUSCH (MD)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANN-BUSCH
Last Name:RICCI
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 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:920-288-5500
Mailing Address - Fax:
Practice Address - Street 1:1160 KEPLER DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-8321
Practice Address - Country:US
Practice Address - Phone:920-288-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087388208000000X
WI22411208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100203349Medicaid