Provider Demographics
NPI:1508168972
Name:RICARDO B MADDELA MD PSC
Entity Type:Organization
Organization Name:RICARDO B MADDELA MD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:NUNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:2708-826-9595
Mailing Address - Street 1:PO BOX 1548
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42419-1548
Mailing Address - Country:US
Mailing Address - Phone:270-826-9595
Mailing Address - Fax:270-826-3656
Practice Address - Street 1:1413 N ELM ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2768
Practice Address - Country:US
Practice Address - Phone:270-826-9595
Practice Address - Fax:270-826-3656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64193139Medicaid
KY1068701Medicare PIN