Provider Demographics
NPI:1851441760
Name:RICKER, BRUCE W (DO)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:W
Last Name:RICKER
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 1:504 N. CLEVELAND ST.
Mailing Address - Street 2:
Mailing Address - City:MOUNT AYR
Mailing Address - State:IA
Mailing Address - Zip Code:50854-2201
Mailing Address - Country:US
Mailing Address - Phone:641-464-3226
Mailing Address - Fax:641-464-4420
Practice Address - Street 1:504 N. CLEVELAND ST.
Practice Address - Street 2:
Practice Address - City:MOUNT AYR
Practice Address - State:IA
Practice Address - Zip Code:50854-2201
Practice Address - Country:US
Practice Address - Phone:641-464-3226
Practice Address - Fax:641-464-4420
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02962207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC002962Medicaid
IA0139626Medicaid
MO245885116Medicaid
IA57934OtherBLUE CROSS
IA8810OtherMIDLAND CHOICE
IAIA0110OtherJOHN DEERE
IA080090856Medicaid
IA930044754Medicaid
IA1139626Medicaid
IA32652Medicare ID - Type UnspecifiedSPECTRUM MEDICARE
IA930044754Medicaid
MO245885116Medicaid