Healthcare Provider Details

I. General information

NPI: 1427219799
Provider Name (Legal Business Name): ROGER DALE RIDGEWAY JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 LT EUGENE J MAJURE DR
PASCAGOULA MS
39581-5305
US

IV. Provider business mailing address

2101 HIGHWAY 90
GAUTIER MS
39553-5340
US

V. Phone/Fax

Practice location:
  • Phone: 228-696-9224
  • Fax: 228-696-9228
Mailing address:
  • Phone: 228-497-7584
  • Fax: 228-497-7586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number31130
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number21922
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: