Provider Demographics
NPI:1588643746
Name:RIDLEY, DIANE M (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:RIDLEY
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 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:1020 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:JERSEY SHORE
Practice Address - State:PA
Practice Address - Zip Code:17740-1729
Practice Address - Country:US
Practice Address - Phone:570-398-5131
Practice Address - Fax:570-398-3195
Is Sole Proprietor?:No
Enumeration Date:2006-01-15
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07775800207L00000X
NY202042207L00000X
PAMD477014207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00953293OtherRR MCR PTAN
NJ0077640Medicaid
NJH17818Medicare UPIN
NJ0077640Medicaid
NJ075928Medicare ID - Type UnspecifiedMEDICARE
NJ147658A01Medicare PIN