Provider Demographics
NPI:1023078623
Name:RICO, SHANNELLE SUSANNE (MD)
Entity type:Individual
Prefix:
First Name:SHANNELLE
Middle Name:SUSANNE
Last Name:RICO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNELLE
Other - Middle Name:SUSANNE
Other - Last Name:RICO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:HWY 77/75
Mailing Address - Street 2:P.O. BOX HH
Mailing Address - City:WINNEBAGO
Mailing Address - State:NE
Mailing Address - Zip Code:68071-0767
Mailing Address - Country:US
Mailing Address - Phone:402-878-2231
Mailing Address - Fax:
Practice Address - Street 1:ROSEBUD IHS HOSPITAL
Practice Address - Street 2:SOLDIER CREEK ROAD
Practice Address - City:ROSEBUD
Practice Address - State:SD
Practice Address - Zip Code:57570-0400
Practice Address - Country:US
Practice Address - Phone:605-747-3245
Practice Address - Fax:605-747-2216
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050363A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000378568OtherBLUE CROSS
IN200381310Medicaid
IN181590HMedicare ID - Type Unspecified
IN200381310Medicaid