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NPI Code Detail

MEDICARE: MR. BRADLEY GENE RIDGE P.A.-C

MEDICARE: MR. BRADLEY GENE RIDGE P.A.-C
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
1363A00000XPhysician Assistant004094GA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1902981996
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. BRADLEY GENE RIDGE P.A.-C
Provider Business Mailing Address
First Line : 3294 NORTH OAK ST. EXT.
Second Line :
City : VALDOSTA
State : GA
Zip : 31605
Country : US
Telephone Number : 229-241-1188
Fax Number : 229-245-7106
Provider Business Practice Location Address
First Line : 3294 NORTH OAK ST. EXT.
Second Line :
City : VALDOSTA
State : GA
Zip : 31605
Country : US
Telephone Number : 229-247-2290
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/26/2006
Last Update Date : 03/07/2012

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