Provider Demographics
NPI:1952322083
Name:RIDGEWAY, MICHAEL GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GLENN
Last Name:RIDGEWAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2366
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-8366
Mailing Address - Country:US
Mailing Address - Phone:916-781-1382
Mailing Address - Fax:916-781-1383
Practice Address - Street 1:1 MEDICAL PLAZA DR
Practice Address - Street 2:TRAUMA SERVICE
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3037
Practice Address - Country:US
Practice Address - Phone:916-781-1382
Practice Address - Fax:916-781-1383
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51663208600000X, 2086S0102X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG45063Medicare UPIN
CA00A516630Medicare ID - Type Unspecified