Provider Demographics
NPI:1154342392
Name:RIDENOUR, ROBERT V III (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:V
Last Name:RIDENOUR
Suffix:III
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 MENOMONIE ST STE B
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-5974
Mailing Address - Country:US
Mailing Address - Phone:715-832-6445
Mailing Address - Fax:
Practice Address - Street 1:3902 OAKWOOD HILLS PKWY STE 2
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-7781
Practice Address - Country:US
Practice Address - Phone:715-858-3260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2025-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN48745207ZP0102X
WI52975207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN572675000Medicaid
MN220001124Medicare PIN
MN220001246Medicare PIN
MN572675000Medicaid