Provider Demographics
NPI:1710062690
Name:NICHOLAS L. RICO, M.D., P.C.
Entity Type:Organization
Organization Name:NICHOLAS L. RICO, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:RICO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-483-4260
Mailing Address - Street 1:3303 TRIER RD STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-4768
Mailing Address - Country:US
Mailing Address - Phone:260-483-4260
Mailing Address - Fax:260-483-6066
Practice Address - Street 1:3303 TRIER RD STE 1
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4768
Practice Address - Country:US
Practice Address - Phone:260-483-4260
Practice Address - Fax:260-483-6066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031164A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100079790AMedicaid
IN197530Medicare PIN
INC24503Medicare UPIN