Provider Demographics
NPI:1396829305
Name:RIDGEWAY, BRADLEY STEVEN (HAD)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:STEVEN
Last Name:RIDGEWAY
Suffix:
Gender:M
Credentials:HAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 SARAINA RD
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-1892
Mailing Address - Country:US
Mailing Address - Phone:317-392-9246
Mailing Address - Fax:317-392-9246
Practice Address - Street 1:504 SARAINA RD
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-1892
Practice Address - Country:US
Practice Address - Phone:317-392-9246
Practice Address - Fax:317-392-9246
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17001166A237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000328327Medicare UPIN
IN80314Medicare UPIN