Healthcare Provider Details

I. General information

NPI: 1508839630
Provider Name (Legal Business Name): STEPHEN FITZGERALD RIDLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

TAYLOR AT MARION
COLUMBIA SC
29220-0001
US

IV. Provider business mailing address

300 E MCBEE AVE # 4TH
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 803-296-5050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number23232
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: