Provider Demographics
NPI:1548262918
Name:RICCIO, CHARLES W (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:RICCIO
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 1:112 E MCMURTRY AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:KY
Mailing Address - Zip Code:42347-1634
Mailing Address - Country:US
Mailing Address - Phone:270-298-7225
Mailing Address - Fax:270-298-4084
Practice Address - Street 1:112 E MCMURTRY AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:KY
Practice Address - Zip Code:42347-1634
Practice Address - Country:US
Practice Address - Phone:270-298-7225
Practice Address - Fax:270-298-4084
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29185207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000050530OtherBLUE CROSS AND BLUE SHIEL
KY110102005OtherRAILROAD MEDICARE
KY65923534Medicaid
KY1062177Medicaid
KY64291859Medicaid
KY1062177Medicaid
KY1573601Medicare PIN
KY000000050530OtherBLUE CROSS AND BLUE SHIEL