Provider Demographics
NPI:1578881181
Name:VIRGIN ISLANDS PEDIATRIC SPECIALTIES, LLC
Entity Type:Organization
Organization Name:VIRGIN ISLANDS PEDIATRIC SPECIALTIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:RICKETTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:340-719-0685
Mailing Address - Street 1:PO BOX 7775
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSTED
Mailing Address - State:VI
Mailing Address - Zip Code:00823-7775
Mailing Address - Country:US
Mailing Address - Phone:340-719-0685
Mailing Address - Fax:340-719-0690
Practice Address - Street 1:4500 SION FARM
Practice Address - Street 2:ISLAND MEDICAL CENTER, SUITE 301
Practice Address - City:CHRISTIANSTED
Practice Address - State:VI
Practice Address - Zip Code:00820-4493
Practice Address - Country:US
Practice Address - Phone:340-719-0685
Practice Address - Fax:340-719-0690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI1103208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty