Provider Demographics
NPI:1366488512
Name:RIDGE ROAD MEDICAL CENTER PA
Entity Type:Organization
Organization Name:RIDGE ROAD MEDICAL CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCKENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-771-8316
Mailing Address - Street 1:2306 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-5140
Mailing Address - Country:US
Mailing Address - Phone:972-771-8316
Mailing Address - Fax:972-722-9214
Practice Address - Street 1:2306 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-5140
Practice Address - Country:US
Practice Address - Phone:972-771-8316
Practice Address - Fax:972-722-9214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091844301Medicaid
TX091844302Medicaid
TX091844301Medicaid