Provider Demographics
NPI:1851441687
Name:RAYMOND ALDRIDGE MD PC
Entity Type:Organization
Organization Name:RAYMOND ALDRIDGE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIANOWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:ALDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:229-891-3325
Mailing Address - Street 1:#3 HOSPITAL PARK
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6772
Mailing Address - Country:US
Mailing Address - Phone:229-891-3325
Mailing Address - Fax:
Practice Address - Street 1:1812 LEE AVE
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3639
Practice Address - Country:US
Practice Address - Phone:229-382-5114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049415207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000885321GMedicaid
GA000885321GMedicaid
GRP4755Medicare PIN