Provider Demographics
NPI:1669456893
Name:RICCOBENE, ELLEN PATRICIA NOLAN
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:PATRICIA NOLAN
Last Name:RICCOBENE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:2ND TPI
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-926-9019
Mailing Address - Fax:215-226-8286
Practice Address - Street 1:9331 OLD BUSTLETON AVE
Practice Address - Street 2:STE 201
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115
Practice Address - Country:US
Practice Address - Phone:215-602-8500
Practice Address - Fax:215-676-6507
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAM2419567207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2968415OtherAETNA PPO
PA3Y4906OtherHEALTH NET
PA10515OtherBRAVO HEALTH
PA2100579000OtherINDEPENDENCE BLUE CROSS
PA3209011OtherAETNA HMO
PAP00025010OtherRAILROAD MEDICARE
PA3009673OtherKEYSTONE MERCY HEALTH
PA1413820OtherHIGHMARK BLUE SHIELD
PA064393Medicare PIN
PA3209011OtherAETNA HMO