Healthcare Provider Details

I. General information

NPI: 1790274850
Provider Name (Legal Business Name): CEDAR RIDGE CRITICAL CARE MEDICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 12/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 DUNLOP LN
CLARKSVILLE TN
37040-5015
US

IV. Provider business mailing address

PO BOX 11531
DAYTONA BEACH FL
32120-1531
US

V. Phone/Fax

Practice location:
  • Phone: 931-502-1000
  • Fax: 386-274-7801
Mailing address:
  • Phone: 386-274-7800
  • Fax: 386-274-7801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: STEVEN P MARON
Title or Position: PRESIDENT
Credential: MD
Phone: 925-482-8233