Healthcare Provider Details

I. General information

NPI: 1164403309
Provider Name (Legal Business Name): ANDREW RICCI JR JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SEYMOUR STREET
HARTFORD CT
06102-5037
US

IV. Provider business mailing address

99 EAST RIVER DR
EAST HARTFORD CT
06108-7301
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-2249
  • Fax: 860-545-2249
Mailing address:
  • Phone: 860-282-4133
  • Fax: 860-289-0742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number024645
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number024645
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: