1801516018 NPI number — MRS. KRISTEN MARIE RIDGE PA

Table of content: MRS. KRISTEN MARIE RIDGE PA (NPI 1801516018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801516018 NPI number — MRS. KRISTEN MARIE RIDGE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIDGE
Provider First Name:
KRISTEN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GONZALEZ
Provider Other First Name:
KRISTEN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801516018
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 RIVERFRONT BLVD STE 710
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRADENTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34205-8812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-776-4000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170 N LIME AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARASOTA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34237-6122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-867-0127
Provider Business Practice Location Address Fax Number:
941-413-5904
Provider Enumeration Date:
08/29/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 115731400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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