Healthcare Provider Details

I. General information

NPI: 1093711871
Provider Name (Legal Business Name): ROBERT STEVEN RIDDICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2005
Last Update Date: 11/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 7TH ST W
DICKINSON ND
58601-4335
US

IV. Provider business mailing address

1036C SMOKEY HOLW
DICKINSON ND
58601-3672
US

V. Phone/Fax

Practice location:
  • Phone: 701-456-4387
  • Fax:
Mailing address:
  • Phone: 541-217-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number12077
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number12077
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: