Provider Demographics
NPI:1013998723
Name:RIDGEWAY, KEN O (DO)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:O
Last Name:RIDGEWAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46936-1045
Mailing Address - Country:US
Mailing Address - Phone:765-628-3319
Mailing Address - Fax:765-628-5979
Practice Address - Street 1:712 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENTOWN
Practice Address - State:IN
Practice Address - Zip Code:46936-1045
Practice Address - Country:US
Practice Address - Phone:765-628-3319
Practice Address - Fax:765-628-5979
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2000340207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100186930AMedicaid
000000183513OtherANTHEM
10825830OtherCAQH
IN170710DMedicare PIN
IN100186930AMedicaid