Basic Information
| Provider Information | |||||||||
| NPI: | 1790274850 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CEDAR RIDGE CRITICAL CARE MEDICAL GROUP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11531 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321201531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862747800 | ||||||||
| FaxNumber: | 3862747801 | ||||||||
| Practice Location | |||||||||
| Address1: | 651 DUNLOP LN | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370405015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315021000 | ||||||||
| FaxNumber: | 3862747801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2018 | ||||||||
| LastUpdateDate: | 12/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | MARON | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9254828233 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207RC0200X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
No ID Information.