Healthcare Provider Details

I. General information

NPI: 1568049286
Provider Name (Legal Business Name): GRANT RIDGWAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2021
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 W SHARON RD
CINCINNATI OH
45246-4137
US

IV. Provider business mailing address

212 W SHARON RD
CINCINNATI OH
45246-4137
US

V. Phone/Fax

Practice location:
  • Phone: 513-771-7213
  • Fax: 513-771-4356
Mailing address:
  • Phone: 513-771-7213
  • Fax: 513-771-4356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.151785
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: