Provider Demographics
NPI:1245228121
Name:RIDLEN, MARK S (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:RIDLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 METRO CENTER BLVD STE 2000
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1785
Mailing Address - Country:US
Mailing Address - Phone:401-432-2520
Mailing Address - Fax:401-453-8220
Practice Address - Street 1:125 METRO CENTER BLVD STE 2000
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1785
Practice Address - Country:US
Practice Address - Phone:401-432-2520
Practice Address - Fax:401-453-8220
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI71322085R0202X
MA1548652085R0202X
RIMD071322085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1600241OtherUNITED HEALTH PLANS
7132OtherFEP BLUE CROSS
007000613OtherHOSPITAL PIN
007132OtherTUFTS
MA2013789Medicaid
7000613OtherRIMEDICAL ASSISTANCE
003117240OtherCT MED ASSISTANCE
007132OtherBLUE SHIELD
240156OtherW&I PILGRIM
000000001988OtherNHPRI
004372OtherBLUE CHIP
300067430OtherRAILROAD MEDICARE
240156OtherRIHPILGRIM
720051701OtherCIGNA
007132OtherBLUE SHIELD
300067430OtherRAILROAD MEDICARE