Healthcare Provider Details

I. General information

NPI: 1326508383
Provider Name (Legal Business Name): ADAM RIDLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2019
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 LINCOLN ST
WORCESTER MA
01605-2120
US

IV. Provider business mailing address

PO BOX 415348
BOSTON MA
02241-5348
US

V. Phone/Fax

Practice location:
  • Phone: 508-334-1352
  • Fax: 508-334-5146
Mailing address:
  • Phone: 800-225-8885
  • Fax: 508-334-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number1016759
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: