Provider Demographics
NPI:1790716611
Name:RICCI, MICHAEL T (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:RICCI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 84432
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-5732
Mailing Address - Country:US
Mailing Address - Phone:206-248-9729
Mailing Address - Fax:206-431-5231
Practice Address - Street 1:16251 SYLVESTER RD SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98166
Practice Address - Country:US
Practice Address - Phone:206-248-9729
Practice Address - Fax:206-431-5231
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000153122085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8192908Medicaid
WAP00368067Medicare PIN
WA8801792Medicare PIN
WA8192908Medicaid