Provider Demographics
NPI:1558674812
Name:RIDGILL, TRACY DEBOLT (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:DEBOLT
Last Name:RIDGILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 W WESMARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-1900
Mailing Address - Country:US
Mailing Address - Phone:803-469-7950
Mailing Address - Fax:803-469-7560
Practice Address - Street 1:649 W WESMARK BLVD
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1900
Practice Address - Country:US
Practice Address - Phone:803-469-7950
Practice Address - Fax:803-469-7560
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-15
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32777207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC327774Medicaid
SCAA6977F694Medicare PIN