Healthcare Provider Details

I. General information

NPI: 1396829305
Provider Name (Legal Business Name): BRADLEY STEVEN RIDGEWAY H.A.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 SARAINA RD
SHELBYVILLE IN
46176-1892
US

IV. Provider business mailing address

504 SARAINA RD
SHELBYVILLE IN
46176-1892
US

V. Phone/Fax

Practice location:
  • Phone: 317-392-9246
  • Fax: 317-392-9246
Mailing address:
  • Phone: 317-392-9246
  • Fax: 317-392-9246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number17001166A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: