Healthcare Provider Details

I. General information

NPI: 1578881181
Provider Name (Legal Business Name): VIRGIN ISLANDS PEDIATRIC SPECIALTIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2010
Last Update Date: 05/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 SION FARM ISLAND MEDICAL CENTER, SUITE 301
CHRISTIANSTED VI
00820-4493
US

IV. Provider business mailing address

PO BOX 7775
CHRISTIANSTED VI
00823-7775
US

V. Phone/Fax

Practice location:
  • Phone: 340-719-0685
  • Fax: 340-719-0690
Mailing address:
  • Phone: 340-719-0685
  • Fax: 340-719-0690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1103
License Number StateVI

VIII. Authorized Official

Name: DR. ANTHONY DAVID RICKETTS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: M.D.
Phone: 340-719-0685