MEDICARE: DR. JAY RIDDLE M.D.

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	171000000X	Military Health Care Provider	54289	VA

General Provider Information

NPI Number	:	1457341893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAY RIDDLE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1327
Second Line	:
City	:	FORT BELVOIR
State	:	VA
Zip	:	22060-1027
Country	:	US
Telephone Number	:	703-805-0193
Fax Number	:

Provider Business Practice Location Address
First Line	:	9501 FARRELL RD
Second Line	:	SUITE GC-11
City	:	FORT BELVOIR
State	:	VA
Zip	:	22060-5901
Country	:	US
Telephone Number	:	703-805-0193
Fax Number	:

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

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	03/26/2010

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