Provider Demographics
NPI:1730292079
Name:FICI, RICHARD A (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:FICI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20905 E 12 MILE RD
Mailing Address - Street 2:STE 300
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-6501
Mailing Address - Country:US
Mailing Address - Phone:586-772-0727
Mailing Address - Fax:586-772-0640
Practice Address - Street 1:20905 E 12 MILE RD
Practice Address - Street 2:STE 300
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-6501
Practice Address - Country:US
Practice Address - Phone:586-772-0727
Practice Address - Fax:586-772-0640
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008247207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIA74297Medicare UPIN
MI1671064Medicare ID - Type Unspecified
MIP56020001Medicare PIN