MEDICARE: KEN O RIDGEWAY DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	2000340	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000183513	OTHER	ANTHEM
3	10825830	OTHER	CAQH

General Provider Information

NPI Number	:	1013998723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEN O RIDGEWAY DO

Provider Business Mailing Address
First Line	:	712 W MAIN ST
Second Line	:
City	:	GREENTOWN
State	:	IN
Zip	:	46936-1045
Country	:	US
Telephone Number	:	765-628-3319
Fax Number	:	765-628-5979

Provider Business Practice Location Address
First Line	:	712 W MAIN ST
Second Line	:
City	:	GREENTOWN
State	:	IN
Zip	:	46936-1045
Country	:	US
Telephone Number	:	765-628-3319
Fax Number	:	765-628-5979

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	10/24/2007

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Directions to “ KEN O RIDGEWAY DO” Practice Location

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