Provider Demographics
NPI:1366712564
Name:T. MARK RICKETTS, M.D., LLC
Entity type:Organization
Organization Name:T. MARK RICKETTS, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:RICKETTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-822-8233
Mailing Address - Street 1:2010 PATTON CHAPEL RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35216-5782
Mailing Address - Country:US
Mailing Address - Phone:205-822-8233
Mailing Address - Fax:205-822-0235
Practice Address - Street 1:2010 PATTON CHAPEL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35216-5782
Practice Address - Country:US
Practice Address - Phone:205-822-8233
Practice Address - Fax:205-822-0235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13998207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC70353Medicare UPIN