MEDICARE: DR. HAL BLAKE RIDGWAY 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	207N00000X	Dermatology Physician	ME0054995	FL

General Provider Information

NPI Number	:	1710986005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HAL BLAKE RIDGWAY M.D.

Provider Business Mailing Address
First Line	:	1760 N CONGRESS AVE
Second Line	:	SUITE 200
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33426-8214
Country	:	US
Telephone Number	:	561-733-0077
Fax Number	:	561-733-0022

Provider Business Practice Location Address
First Line	:	1760 N CONGRESS AVE
Second Line	:	SUITE 200
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33426-8214
Country	:	US
Telephone Number	:	561-733-0077
Fax Number	:	561-733-0022

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

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	02/09/2011

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