Provider Demographics
NPI:1962634170
Name:MAL S RIDDELL, D.O. CLINIC
Entity Type:Organization
Organization Name:MAL S RIDDELL, D.O. CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAL
Authorized Official - Middle Name:S
Authorized Official - Last Name:RIDDELL
Authorized Official - Suffix:III
Authorized Official - Credentials:DO
Authorized Official - Phone:662-226-6430
Mailing Address - Street 1:1300 SUNSET DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-4086
Mailing Address - Country:US
Mailing Address - Phone:662-226-6430
Mailing Address - Fax:662-226-0018
Practice Address - Street 1:1300 SUNSET DR
Practice Address - Street 2:SUITE B
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4086
Practice Address - Country:US
Practice Address - Phone:662-226-6430
Practice Address - Fax:662-226-0018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-20
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty