Basic Information
| Provider Information | |||||||||
| NPI: | 1932136744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIDDLE | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2326 18TH ST | ||||||||
| Address2: | STE 210 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472015359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123728426 | ||||||||
| FaxNumber: | 8123728301 | ||||||||
| Practice Location | |||||||||
| Address1: | 2326 18TH ST | ||||||||
| Address2: | STE 210 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472015359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123728426 | ||||||||
| FaxNumber: | 8123728301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 05/06/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01044582A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 054468P | 01 | SIHO | OTHER | 200056040 | 05 | IN | MEDICAID | 1790837789 | 01 | IN | GROUP NPI | OTHER | 00000056040 | 01 | ANTHEM | OTHER | P00137831 | 01 | IN | MEDICARE RAILROAD | OTHER |