Healthcare Provider Details

I. General information

NPI: 1417385881
Provider Name (Legal Business Name): BRAD MICHAEL RICKABAUGH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2013
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE
DANVILLE PA
17822-9800
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-9800
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-6812
  • Fax: 570-214-9442
Mailing address:
  • Phone: 570-271-6812
  • Fax: 570-214-9442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberOT021603
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: