Provider Demographics
NPI:1295197093
Name:SIWICKI & RICCIARDI PL
Entity Type:Organization
Organization Name:SIWICKI & RICCIARDI PL
Other - Org Name:EMERALD COAST PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICCIARDI
Authorized Official - Middle Name:A
Authorized Official - Last Name:RICCIARDI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:850-682-6522
Mailing Address - Street 1:120 E REDSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-5370
Mailing Address - Country:US
Mailing Address - Phone:850-682-6522
Mailing Address - Fax:
Practice Address - Street 1:849 S THREE NOTCH ST
Practice Address - Street 2:
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420-5325
Practice Address - Country:US
Practice Address - Phone:850-682-6522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340598200Medicaid
FL340598200Medicaid