Provider Demographics
NPI:1639442742
Name:JEFFREY R. RIDHA M.D. P.C.
Entity Type:Organization
Organization Name:JEFFREY R. RIDHA M.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:RIDHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-306-5466
Mailing Address - Street 1:72 RAILROAD PL
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-3008
Mailing Address - Country:US
Mailing Address - Phone:518-306-5466
Mailing Address - Fax:518-306-5470
Practice Address - Street 1:72 RAILROAD PL
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-3008
Practice Address - Country:US
Practice Address - Phone:518-306-5466
Practice Address - Fax:518-306-5470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-21
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229760261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ100072789OtherMEDICARE PTAN