Provider Demographics
NPI:1609136993
Name:RIDDLE, ELIJAH WADE (MD)
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:WADE
Last Name:RIDDLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-6156
Mailing Address - Fax:
Practice Address - Street 1:735 NORMAN DR STE 3
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7559
Practice Address - Country:US
Practice Address - Phone:717-270-7908
Practice Address - Fax:717-272-1734
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT201557208600000X
PAMD4541802086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery