Provider Demographics
NPI:1043253727
Name:GARY C RIDENOUR MD A PROF CORP
Entity Type:Organization
Organization Name:GARY C RIDENOUR MD A PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:RIDENOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-423-6400
Mailing Address - Street 1:PO BOX 1912
Mailing Address - Street 2:
Mailing Address - City:FALLON
Mailing Address - State:NV
Mailing Address - Zip Code:89407
Mailing Address - Country:US
Mailing Address - Phone:775-423-6400
Mailing Address - Fax:775-423-9411
Practice Address - Street 1:625 W WILLIAMS AVE
Practice Address - Street 2:STE B
Practice Address - City:FALLON
Practice Address - State:NV
Practice Address - Zip Code:89406
Practice Address - Country:US
Practice Address - Phone:775-423-6400
Practice Address - Fax:775-423-9411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002001209Medicaid
NVVMD4525Medicare ID - Type Unspecified
C96500Medicare UPIN