MEDICARE: RIDGE MEDICAL ASSOCIATES, LLC

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	207R00000X	Internal Medicine Physician	ME74564	FL

General Provider Information

NPI Number	:	1427271931
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIDGE MEDICAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	405 S 11TH ST
Second Line	:
City	:	LAKE WALES
State	:	FL
Zip	:	33853-4202
Country	:	US
Telephone Number	:	863-679-8000
Fax Number	:	863-679-8008

Provider Business Practice Location Address
First Line	:	405 S 11TH ST
Second Line	:
City	:	LAKE WALES
State	:	FL
Zip	:	33853-4202
Country	:	US
Telephone Number	:	863-679-8000
Fax Number	:	863-679-8008

Authorized Official
Title or Position	:	MD
Name	:	DR. NIHALANI K SUNIL
Credential	:
Telephone Number	:	863-679-8000

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	08/22/2020

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