Provider Demographics
NPI:1770587651
Name:RICE, STANLEY MILTON (PAC)
Entity type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:MILTON
Last Name:RICE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 S LANDMARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-5003
Mailing Address - Country:US
Mailing Address - Phone:812-332-4468
Mailing Address - Fax:812-331-3311
Practice Address - Street 1:421 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5003
Practice Address - Country:US
Practice Address - Phone:812-332-4468
Practice Address - Fax:812-331-3311
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000131A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INR33601Medicare UPIN
IN542460DMedicare ID - Type UnspecifiedMEDICARE