Provider Demographics
NPI:1043246887
Name:RIDYARD, HERBERT W JR (MD)
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:W
Last Name:RIDYARD
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HOSPITAL DR STE 260
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-5283
Mailing Address - Country:US
Mailing Address - Phone:865-471-2250
Mailing Address - Fax:865-471-2251
Practice Address - Street 1:120 HOSPITAL DR STE 260
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-5283
Practice Address - Country:US
Practice Address - Phone:865-471-2250
Practice Address - Fax:865-471-2251
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD52380208600000X
CT023949208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT051357OtherHEALTHNET
CT757224OtherCONNECTICARE
CT001239490OtherBLUE CARE FAMILY PLAN
CT010023949CT03OtherANTHEM BLUE CROSS / BLUE
CT0782058OtherAETNA/US HEALTHCARE
CTWIS019OtherOXFORD HEALTH PLAN
CTP02114OtherCHN
CT001239490Medicaid
CT1280734005OtherCIGNA
CT757224OtherCONNECTICARE
CT051357OtherHEALTHNET
CT001239490Medicaid