Healthcare Provider Details

I. General information

NPI: 1043398456
Provider Name (Legal Business Name): GREGORY ALLEN RIDDLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1599 JONES STREET
GRAND FORKS AFB ND
58205
US

IV. Provider business mailing address

1599 JONES STREET
GRAND FORKS AFB ND
58205
US

V. Phone/Fax

Practice location:
  • Phone: 701-747-5326
  • Fax:
Mailing address:
  • Phone: 701-747-5326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19406
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number19406
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number19406
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: