MEDICARE: DAVID AUSTIN RIDEOUT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	80575	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MR0177685A	OTHER	MA	MA CONTROLLED SUBSTANCES

General Provider Information

NPI Number	:	1396810206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID AUSTIN RIDEOUT M.D.

Provider Business Mailing Address
First Line	:	1028 WASHINGTON ST
Second Line	:
City	:	GLOUCESTER
State	:	MA
Zip	:	01930-1162
Country	:	US
Telephone Number	:	978-281-5756
Fax Number	:	978-281-8157

Provider Business Practice Location Address
First Line	:	60 WASHINGTON ST STE 403
Second Line	:
City	:	SALEM
State	:	MA
Zip	:	01970-3517
Country	:	US
Telephone Number	:	978-594-0816
Fax Number	:	978-594-5878

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/24/2006
Last Update Date	:	03/07/2023

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