Provider Demographics
NPI:1760692388
Name:ROBERT S RIDDICK MDPC
Entity Type:Organization
Organization Name:ROBERT S RIDDICK MDPC
Other - Org Name:RIDDICK SURGICAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:RIDDICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-538-8545
Mailing Address - Street 1:PO BOX 1047
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-1047
Mailing Address - Country:US
Mailing Address - Phone:912-538-8545
Mailing Address - Fax:
Practice Address - Street 1:106 QUEEN STREET
Practice Address - Street 2:SUITE 4
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474
Practice Address - Country:US
Practice Address - Phone:912-538-8545
Practice Address - Fax:912-538-8547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054933208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6799OtherMEDICARE GROUP NUMBER
GAGRP6799OtherMEDICARE GROUP NUMBER
GAF94339Medicare UPIN