Provider Demographics
NPI:1881987998
Name:RIDGE AVENUE SPORTS MEDICINE, INC.
Entity type:Organization
Organization Name:RIDGE AVENUE SPORTS MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARCY
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:SOCRATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-664-7700
Mailing Address - Street 1:514 N 24TH ST
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-4917
Mailing Address - Country:US
Mailing Address - Phone:484-664-7700
Mailing Address - Fax:484-664-7701
Practice Address - Street 1:1150 GLENLIVET DR
Practice Address - Street 2:A-21
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18106-3112
Practice Address - Country:US
Practice Address - Phone:484-664-7700
Practice Address - Fax:484-664-7701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-23
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025425E261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty