Provider Demographics
NPI:1184761488
Name:RIDGEWAY, NATHAN ALVAH (M D)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:ALVAH
Last Name:RIDGEWAY
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 BIRCHFIELD PVT CT
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-6428
Mailing Address - Country:US
Mailing Address - Phone:423-392-4622
Mailing Address - Fax:
Practice Address - Street 1:1105 W STONE DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-2558
Practice Address - Country:US
Practice Address - Phone:423-246-0010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD4673207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3177901Medicare ID - Type UnspecifiedPROVIDER
TNB01772Medicare UPIN