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General NPI Number Information
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NPI Number | 1760692388
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Entity Type | Organization
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Legal Business Name | ROBERT S RIDDICK MDPC
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Dates
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Enumeration Date | 05/23/2007
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Last Update Date | 12/28/2007
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Provider Practice Location Address
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Address Line | 106 QUEEN STREET SUITE 4
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City | VIDALIA
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State | GA
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Zip | 30474
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Country | US
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Telephone | 912-538-8545
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Fax | 912-538-8547
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Provider Business Mailing Address
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Address Line | PO BOX 1047
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City | VIDALIA
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State | GA
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Zip | 30475-1047
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Country | US
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Telephone | 912-538-8545
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN OWNER
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Name | DR. ROBERT STEVEN RIDDICK
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Credential | MD
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Telephone | 912-538-8545
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 054933
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License Number State | GA
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