Basic Information
| Provider Information | |||||||||
| NPI: | 1013025022 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIDGE MANOR FAMILY MEDICINE,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31158 CORTEZ BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346027552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527965303 | ||||||||
| FaxNumber: | 3527965304 | ||||||||
| Practice Location | |||||||||
| Address1: | 31158 CORTEZ BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346027552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527965303 | ||||||||
| FaxNumber: | 3527965304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BOWDEN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3527965303 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS6302 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.