Provider Demographics
NPI:1295768851
Name:ROBERT M. RICKETTS, MD, PA
Entity type:Organization
Organization Name:ROBERT M. RICKETTS, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MASON
Authorized Official - Last Name:RICKETTS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:410-876-9111
Mailing Address - Street 1:910 WASHINGTON RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-5827
Mailing Address - Country:US
Mailing Address - Phone:410-876-9111
Mailing Address - Fax:410-857-3345
Practice Address - Street 1:910 WASHINGTON RD
Practice Address - Street 2:SUITE E
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-5827
Practice Address - Country:US
Practice Address - Phone:410-876-9111
Practice Address - Fax:410-857-3345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0039296174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD629050OtherMAMSI/UHC PROVIDER#
MD2534363OtherAETNA PROV #
MD2500754OtherUHC PROVIDER#
MD596AROOtherBC & BS MEMBER #
MD2500754OtherUHC PROVIDER#
MD596AROOtherBC & BS MEMBER #
MD873MMedicare ID - Type Unspecified