Provider Demographics
NPI:1578570792
Name:RICCI, KENNETH J (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:RICCI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10745 WESTSIDE WAY STE 125
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-7635
Mailing Address - Country:US
Mailing Address - Phone:770-410-4610
Mailing Address - Fax:888-990-1674
Practice Address - Street 1:10745 WESTSIDE WAY STE 125
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-7635
Practice Address - Country:US
Practice Address - Phone:770-410-4610
Practice Address - Fax:888-990-1674
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034932207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
08LCCFJMedicare ID - Type Unspecified
F47183Medicare UPIN