Provider Demographics
NPI:1275621955
Name:REICKERT, CRAIG A (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:A
Last Name:REICKERT
Suffix:
Gender:M
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:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:2799 WEST GRAND BOULEVARD
Mailing Address - City:DETOIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-916-2600
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:2799 WEST GRAND BOULEVARD
Practice Address - City:DETOIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-916-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010594392086S0102X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI454306810Medicaid
CR059439OtherCOMMERCIAL-COMMERCIAL NUMBER
280H264470OtherBLUE CROSS-BLUE CROSS
CR059439OtherCHAMPUS-CHAMPUS
0H26447010Medicare ID - Type Unspecified
CR059439OtherCOMMERCIAL-COMMERCIAL NUMBER