Healthcare Provider Details

I. General information

NPI: 1659960573
Provider Name (Legal Business Name): MR. ROSARIO ANTHONY RICCABENE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2021
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3480 VETERANS MEMORIAL HWY
BOHEMIA NY
11716-1068
US

IV. Provider business mailing address

7 CLAIRE LN
SAYVILLE NY
11782-2420
US

V. Phone/Fax

Practice location:
  • Phone: 631-289-0531
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number003427
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: