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General NPI Number Information
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NPI Number | 1023233749
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Entity Type | Organization
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Legal Business Name | RIDGEWOOD CLINICS PA
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Dates
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Enumeration Date | 04/16/2007
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Last Update Date | 08/27/2014
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Provider Practice Location Address
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Address Line | 1059 RIDGEWOOD CLINIC
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City | JACKSON
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State | MS
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Zip | 39211
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Country | US
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Telephone | 601-957-3211
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Fax | 601-957-9753
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Provider Business Mailing Address
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Address Line | 1059 RIDGEWOOD CLINIC
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City | JACKSON
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State | MS
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Zip | 39211
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Country | US
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Telephone | 601-957-3211
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Fax | 601-957-9753
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Authorized Official
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Title or Position | PHYSICIAN
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Name | KRISHAN K. GUPTA
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Credential | M.D.
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Telephone | 601-957-3211
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 12941
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License Number State | MS
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