Healthcare Provider Details

I. General information

NPI: 1023078623
Provider Name (Legal Business Name): SHANNELLE SUSANNE RICO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNELLE SUSANNE RICO MD

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 07/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROSEBUD IHS HOSPITAL SOLDIER CREEK ROAD
ROSEBUD SD
57570-0400
US

IV. Provider business mailing address

HWY 77/75 P.O. BOX HH
WINNEBAGO NE
68071-0767
US

V. Phone/Fax

Practice location:
  • Phone: 605-747-3245
  • Fax: 605-747-2216
Mailing address:
  • Phone: 402-878-2231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01050363A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: