Provider Demographics
NPI:1023233749
Name:RIDGEWOOD CLINICS PA
Entity type:Organization
Organization Name:RIDGEWOOD CLINICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KRISHAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-957-3211
Mailing Address - Street 1:1059 RIDGEWOOD CLINIC
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211
Mailing Address - Country:US
Mailing Address - Phone:601-957-3211
Mailing Address - Fax:601-957-9753
Practice Address - Street 1:1059 RIDGEWOOD CLINIC
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211
Practice Address - Country:US
Practice Address - Phone:601-957-3211
Practice Address - Fax:601-957-9753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12941101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013996Medicaid
MS=========Medicaid
MS09013996Medicaid