Provider Demographics
NPI:1457381345
Name:RICKELMAN, RAYMOND (PA-C)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:RICKELMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 E 22ND ST STE 110
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6100
Mailing Address - Country:US
Mailing Address - Phone:630-376-6317
Mailing Address - Fax:630-376-6319
Practice Address - Street 1:2852 MAYFAIR AVE
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-5009
Practice Address - Country:US
Practice Address - Phone:208-559-3757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-005070363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADOOOMedicare UPIN