Provider Demographics
NPI:1104867183
Name:ACKERMAN, RIDDICK III (MD)
Entity Type:Individual
Prefix:DR
First Name:RIDDICK
Middle Name:
Last Name:ACKERMAN
Suffix:III
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 1:400 CONSTANCE ST
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-2710
Mailing Address - Country:US
Mailing Address - Phone:843-549-9568
Mailing Address - Fax:843-549-1530
Practice Address - Street 1:400 CONSTANCE ST
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-2710
Practice Address - Country:US
Practice Address - Phone:843-549-9568
Practice Address - Fax:843-549-1530
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11469207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC114691Medicaid
SC114691Medicaid