Healthcare Provider Details

I. General information

NPI: 1154314979
Provider Name (Legal Business Name): RICKE L SPOTTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 S 8TH ST
LEBANON PA
17042-6721
US

IV. Provider business mailing address

717 S 8TH ST
LEBANON PA
17042-6721
US

V. Phone/Fax

Practice location:
  • Phone: 717-274-6657
  • Fax: 717-270-6615
Mailing address:
  • Phone: 717-274-6657
  • Fax: 717-270-6615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD019767E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: