Provider Demographics
NPI:1952686057
Name:RICKERT, MICHAELA ELISE (RD, PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:ELISE
Last Name:RICKERT
Suffix:
Gender:F
Credentials:RD, PA-C
Other - Prefix:
Other - First Name:MICHAELA
Other - Middle Name:
Other - Last Name:COVELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1860 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0018
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:430 PENNSYLVANIA AVE # 320
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4464
Practice Address - Country:US
Practice Address - Phone:630-668-2180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005079363A00000X
IL1952686057363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1952686057Medicaid