=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508168972
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RICARDO B MADDELA MD PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2010
-----------------------------------------------------
Last Update Date | 11/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1413 N ELM ST
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42420-2768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-826-9595
-----------------------------------------------------
Fax | 270-826-3656
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1548
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42419-1548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-826-9595
-----------------------------------------------------
Fax | 270-826-3656
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RECEPTIONIST
-----------------------------------------------------
Name | MS. MICHELLE LYNN NUNN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 27088269595
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------