Healthcare Provider Details

I. General information

NPI: 1891771432
Provider Name (Legal Business Name): JOHN HENRY RICKELMAN JR. DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

IV. Provider business mailing address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

V. Phone/Fax

Practice location:
  • Phone: 217-223-8400
  • Fax: 217-277-3960
Mailing address:
  • Phone: 217-223-8400
  • Fax: 217-277-3960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036148450
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: