Provider Demographics
NPI:1396763223
Name:RICKERBY, MICHELLE L (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:RICKERBY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:593 EDDY STREET
Mailing Address - Street 2:POTTER 3
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-4318
Mailing Address - Fax:401-444-6573
Practice Address - Street 1:593 EDDY STREET
Practice Address - Street 2:POTTER BASEMENT
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-8638
Practice Address - Fax:401-444-2085
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD098002084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMR27488Medicaid
RIMR27488Medicaid
RI007007236Medicare PIN
RIG78551Medicare UPIN