Basic Information
| Provider Information | |||||||||
| NPI: | 1053300020 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIDGE FAMILY PRACTICE, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RIDGE FAMILY PRACTICE, PC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 RIDGE ST STE 311 | ||||||||
| Address2: | |||||||||
| City: | COUNCIL BLUFFS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515034643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123225899 | ||||||||
| FaxNumber: | 7123225730 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 RIDGE ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | COUNCIL BLUFFS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515034643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123225899 | ||||||||
| FaxNumber: | 7123225730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 02/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | LUND | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7123225899 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.