Healthcare Provider Details

I. General information

NPI: 1811073364
Provider Name (Legal Business Name): ERIC M RIDGWAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 06/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 RIVERVIEW ROAD
RIVERTON WY
82501
US

IV. Provider business mailing address

1620 RIVERVIEW ROAD
RIVERTON WY
82501
US

V. Phone/Fax

Practice location:
  • Phone: 307-856-6591
  • Fax: 307-332-1920
Mailing address:
  • Phone: 307-856-6591
  • Fax: 307-332-1920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3595A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: