MEDICARE: VIRGIN ISLANDS PEDIATRIC SPECIALTIES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	1103	VI

General Provider Information

NPI Number	:	1578881181
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIRGIN ISLANDS PEDIATRIC SPECIALTIES, LLC

Provider Business Mailing Address
First Line	:	PO BOX 7775
Second Line	:
City	:	CHRISTIANSTED
State	:	VI
Zip	:	00823-7775
Country	:	US
Telephone Number	:	340-719-0685
Fax Number	:	340-719-0690

Provider Business Practice Location Address
First Line	:	4500 SION FARM
Second Line	:	ISLAND MEDICAL CENTER, SUITE 301
City	:	CHRISTIANSTED
State	:	VI
Zip	:	00820-4493
Country	:	US
Telephone Number	:	340-719-0685
Fax Number	:	340-719-0690

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	DR. ANTHONY DAVID RICKETTS
Credential	:	M.D.
Telephone Number	:	340-719-0685

Provider Enumeration Date	:	05/06/2010
Last Update Date	:	05/06/2010

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