Provider Demographics
NPI:1902810369
Name:RICKLER, KENNETH C (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:C
Last Name:RICKLER
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 1:345 BLACKSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4800
Mailing Address - Country:US
Mailing Address - Phone:401-455-6200
Mailing Address - Fax:401-455-6309
Practice Address - Street 1:345 BLACKSTONE BLVD
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4800
Practice Address - Country:US
Practice Address - Phone:401-455-6200
Practice Address - Fax:401-455-6309
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD089872084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI25226-5OtherBLUE CROSS
RI1104801349OtherBUTLER HOSPITAL NPI
RI204792OtherBLUE CHIP
RI05-00163OtherUNITED HEALTHCARE
RI9025246Medicaid
RI1093831646OtherBUTLER HOSPITAL PROFESSIONAL BILLING OFFICE
RI269025226Medicare ID - Type Unspecified
RI9025246Medicaid