Provider Demographics
NPI:1801934682
Name:RICCIARELLI, GIACOMO A (MD)
Entity type:Individual
Prefix:
First Name:GIACOMO
Middle Name:A
Last Name:RICCIARELLI
Suffix:
Gender:M
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:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1239
Mailing Address - Country:US
Mailing Address - Phone:248-824-6600
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:263 MCLAWS CIRCLE
Practice Address - Street 2:SUITE 105
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-5629
Practice Address - Country:US
Practice Address - Phone:757-941-5600
Practice Address - Fax:757-564-0557
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101029718207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7305737Medicaid
VA440432OtherANTHEM
VA52244OtherSENTARA HEALTHCARE
VA440432OtherANTHEM