Provider Demographics
NPI:1407865488
Name:RIDGEPARK MEDICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:RIDGEPARK MEDICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:KOEPKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-749-8256
Mailing Address - Street 1:7575 NORTHCLIFF AVE
Mailing Address - Street 2:LABORATORY SUITE 106
Mailing Address - City:BROOKLYN
Mailing Address - State:OH
Mailing Address - Zip Code:44144-3267
Mailing Address - Country:US
Mailing Address - Phone:216-398-5095
Mailing Address - Fax:216-398-5119
Practice Address - Street 1:7575 NORTHCLIFF AVE
Practice Address - Street 2:LABORATORY SUITE 106
Practice Address - City:BROOKLYN
Practice Address - State:OH
Practice Address - Zip Code:44144-3267
Practice Address - Country:US
Practice Address - Phone:216-398-5095
Practice Address - Fax:216-398-5119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36D0338463291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH512593OtherWELLCAREOF OH
OH2754274Medicaid
000000561755OtherANTHEM
OH512593OtherWELLCAREOF OH