Provider Demographics
NPI:1609842988
Name:RIDGE, S BRENT (MD)
Entity Type:Individual
Prefix:
First Name:S
Middle Name:BRENT
Last Name:RIDGE
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:ONE GUSTAVE L LEVY PLACE
Mailing Address - Street 2:BOX 1070
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029
Mailing Address - Country:US
Mailing Address - Phone:212-241-5561
Mailing Address - Fax:212-860-9737
Practice Address - Street 1:1470 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-659-8552
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2189471207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD2554718Medicaid
NYD2554718Medicaid
NY007SM1Medicare ID - Type Unspecified