Provider Demographics
NPI:1760569644
Name:RICCELLI, JAMES E (DM)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:E
Last Name:RICCELLI
Suffix:
Gender:M
Credentials:DM
Other - Prefix:MRS
Other - First Name:LECIA
Other - Middle Name:M
Other - Last Name:RICCELLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:WIFE
Mailing Address - Street 1:4560 BECKER RD
Mailing Address - Street 2:
Mailing Address - City:BREWERTON
Mailing Address - State:NY
Mailing Address - Zip Code:13029-8700
Mailing Address - Country:US
Mailing Address - Phone:315-676-3169
Mailing Address - Fax:315-676-2574
Practice Address - Street 1:5100 W TAFT RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3807
Practice Address - Country:US
Practice Address - Phone:315-452-2200
Practice Address - Fax:315-452-2204
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1541261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA0520Medicare ID - Type Unspecified