Provider Demographics
NPI:1811073364
Name:RIDGWAY, ERIC M (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:M
Last Name:RIDGWAY
Suffix:
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 1:1620 RIVERVIEW ROAD
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501
Mailing Address - Country:US
Mailing Address - Phone:307-856-6591
Mailing Address - Fax:307-332-1920
Practice Address - Street 1:1620 RIVERVIEW ROAD
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501
Practice Address - Country:US
Practice Address - Phone:307-856-6591
Practice Address - Fax:307-332-1920
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3595A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY109170100Medicaid
WY109170100Medicaid