Provider Demographics
NPI:1942220678
Name:RICKELMAN, THERESA T (DO)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:T
Last Name:RICKELMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 CONSORT DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-4439
Mailing Address - Country:US
Mailing Address - Phone:636-386-9224
Mailing Address - Fax:636-386-7679
Practice Address - Street 1:615 S NEW BALLAS RD DEPT OF
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:636-386-9224
Practice Address - Fax:636-386-7679
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001014679207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0976845Medicaid
MO207178708Medicaid
MO8298OtherHEALTHCARE USA (GROUP)
CG4336OtherRAILROAD MEDICARE
MO80174OtherHEALTHCARE USA
P00130500OtherRAILROAD
MO80174OtherHEALTHCARE USA
CG4336OtherRAILROAD MEDICARE