Provider Demographics
NPI:1659549004
Name:RIDGEWOOD MEDICAL CLINIC
Entity Type:Organization
Organization Name:RIDGEWOOD MEDICAL CLINIC
Other - Org Name:KINGLSEY MEDICAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:GELBAR
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:972-271-5544
Mailing Address - Street 1:219 W KINGSLEY RD STE 336
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75041-3434
Mailing Address - Country:US
Mailing Address - Phone:972-271-5544
Mailing Address - Fax:972-271-5567
Practice Address - Street 1:219 W KINGSLEY RD STE 336
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-3434
Practice Address - Country:US
Practice Address - Phone:972-271-5544
Practice Address - Fax:972-271-5567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00969208D00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE67876Medicare UPIN