Provider Demographics
NPI:1669700415
Name:RIDDLE, MICHAEL D
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:RIDDLE
Suffix:
Gender:M
Credentials:
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 636256
Mailing Address - Street 2:CENTRAL CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2364
Mailing Address - Country:US
Mailing Address - Phone:513-585-5502
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-585-5502
Practice Address - Fax:513-585-5511
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-04
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.320325-COA1163W00000X
OHCOA.11549-NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3090855Medicaid
IN200993040Medicaid
KY7100125100Medicaid
OH3090855Medicaid