Provider Demographics
NPI:1134188238
Name:RIDDLE, SAMUEL M III (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:M
Last Name:RIDDLE
Suffix:III
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 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:115 N SUMTER ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4972
Practice Address - Country:US
Practice Address - Phone:803-775-8351
Practice Address - Fax:803-774-1512
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12846207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC128463Medicaid
SCC606127124OtherMEDICARE ID
SC128463Medicaid
SCSC7980F694Medicare PIN
SCC606121719Medicare ID - Type Unspecified
SCC60612Medicare UPIN