Provider Demographics
NPI:1063909695
Name:RIDGE, IAN (MD)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:RIDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-3008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3394 E JOLLY RD STE A
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-8595
Practice Address - Country:US
Practice Address - Phone:517-253-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2025-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1063909695207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery