Healthcare Provider Details

I. General information

NPI: 1922842798
Provider Name (Legal Business Name): RIDLEY S SHELBY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 09/12/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
WRIGHT PATTERSON AFB OH
45433-5529
US

IV. Provider business mailing address

304 LONGFELLOW LN
COLUMBIA MO
65203-1625
US

V. Phone/Fax

Practice location:
  • Phone: 937-522-2778
  • Fax:
Mailing address:
  • Phone: 573-864-0178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number58.035861
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: