Provider Demographics
NPI:1679612733
Name:RIDGEWAY FAMILY PRACTICE, PC
Entity type:Organization
Organization Name:RIDGEWAY FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:706-335-2034
Mailing Address - Street 1:641 HOSPITAL RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:COMMERCE
Mailing Address - State:GA
Mailing Address - Zip Code:30529-1155
Mailing Address - Country:US
Mailing Address - Phone:706-335-2034
Mailing Address - Fax:706-336-8638
Practice Address - Street 1:641 HOSPITAL RD
Practice Address - Street 2:SUITE 3
Practice Address - City:COMMERCE
Practice Address - State:GA
Practice Address - Zip Code:30529-1155
Practice Address - Country:US
Practice Address - Phone:706-335-2034
Practice Address - Fax:706-336-8638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2010001281-58996261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6629OtherMEDICARE GROUP NUMBER
GA85002412GMedicaid