Provider Demographics
NPI:1730134073
Name:RICCA, GLEN L (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:L
Last Name:RICCA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-2223
Mailing Address - Country:US
Mailing Address - Phone:815-672-4587
Mailing Address - Fax:815-673-3582
Practice Address - Street 1:109 E ELM ST
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-2223
Practice Address - Country:US
Practice Address - Phone:815-672-4587
Practice Address - Fax:815-673-3582
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060768207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD14438Medicare UPIN