Provider Demographics
NPI:1922736842
Name:RIDGE MEDICAL GROUP PA
Entity Type:Organization
Organization Name:RIDGE MEDICAL GROUP PA
Other - Org Name:THE RIDGE FOOT AND ANKLE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRADEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-881-2100
Mailing Address - Street 1:2677 E 17TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6612
Mailing Address - Country:US
Mailing Address - Phone:208-741-3660
Mailing Address - Fax:
Practice Address - Street 1:2677 E 17TH ST STE 200
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6612
Practice Address - Country:US
Practice Address - Phone:208-741-3660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-09
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty