Provider Demographics
NPI:1316255854
Name:RICKERT, S DIANE (MD)
Entity type:Individual
Prefix:DR
First Name:S
Middle Name:DIANE
Last Name:RICKERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8569 BRADLEYS LANDING ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-6909
Mailing Address - Country:US
Mailing Address - Phone:315-480-4241
Mailing Address - Fax:
Practice Address - Street 1:117 KITE RD
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401-3231
Practice Address - Country:US
Practice Address - Phone:478-289-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-17
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY259148207P00000X
PAMD447350207PE0004X
GA80174207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400037621Medicare PIN
NYJ400034215Medicare PIN