Provider Demographics
NPI:1427130772
Name:KACICH, RAYMOND L (MD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:L
Last Name:KACICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 S 6TH AVE # 1-11C
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85723-0001
Mailing Address - Country:US
Mailing Address - Phone:520-429-2580
Mailing Address - Fax:520-629-4976
Practice Address - Street 1:3601 S 6TH AVE # 1-11C
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85723-5104
Practice Address - Country:US
Practice Address - Phone:520-429-2580
Practice Address - Fax:520-629-4976
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-086191174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036086191Medicaid
IL060021806OtherRAILROAD
IL060021806OtherRAILROAD
ILL81858Medicare PIN
IL036086191Medicaid