Provider Demographics
NPI:1225386691
Name:RICKERTSEN, MICHAEL BRUCE (CTA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:BRUCE
Last Name:RICKERTSEN
Suffix:
Gender:M
Credentials:CTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2444 O ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-1125
Mailing Address - Country:US
Mailing Address - Phone:402-475-7666
Mailing Address - Fax:402-476-9623
Practice Address - Street 1:904 SUMNER ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502-2154
Practice Address - Country:US
Practice Address - Phone:402-434-2670
Practice Address - Fax:402-434-2670
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470398819Medicaid