Provider Demographics
NPI:1891975587
Name:RIDDLE HEALTH CENTER LLC
Entity Type:Organization
Organization Name:RIDDLE HEALTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:RIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-434-6832
Mailing Address - Street 1:2717 MIAMISBURG CENTERVILLE RD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-3797
Mailing Address - Country:US
Mailing Address - Phone:937-434-6832
Mailing Address - Fax:937-434-8371
Practice Address - Street 1:2717 MIAMISBURG CENTERVILLE RD
Practice Address - Street 2:SUITE 211
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-3797
Practice Address - Country:US
Practice Address - Phone:937-434-6832
Practice Address - Fax:937-434-8371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35059114207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0834342OtherMEDICAID PROVIDER NUMBER
OHE76546Medicare UPIN
OH9338731Medicare PIN