Provider Demographics
NPI:1699177055
Name:RARICK, BRAD (PA)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:RARICK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 N MAIN ST
Mailing Address - Street 2:STE 202
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1165
Mailing Address - Country:US
Mailing Address - Phone:937-832-9700
Mailing Address - Fax:937-832-8663
Practice Address - Street 1:9000 N MAIN ST
Practice Address - Street 2:STE 202
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45415-1165
Practice Address - Country:US
Practice Address - Phone:937-832-9700
Practice Address - Fax:937-832-8663
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-17
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004118363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0110556Medicaid
OHH378350Medicare PIN