Provider Demographics
NPI:1619105103
Name:TRICOCI, MICHAEL CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHARLES
Last Name:TRICOCI
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 1:2800 W LIBERTY CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47932-8038
Mailing Address - Country:US
Mailing Address - Phone:312-399-4935
Mailing Address - Fax:
Practice Address - Street 1:412 N MONROE ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:IN
Practice Address - Zip Code:47993-1049
Practice Address - Country:US
Practice Address - Phone:765-762-4050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01071498A207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201083110Medicaid
IN809640001Medicare PIN
IN226540001Medicare PIN