Provider Demographics
NPI:1285609214
Name:RIDGEPARK MEDICAL ASSOCIATES INC
Entity type:Organization
Organization Name:RIDGEPARK MEDICAL ASSOCIATES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:KOEPKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-749-8276
Mailing Address - Street 1:1440 ROCKSIDE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-2749
Mailing Address - Country:US
Mailing Address - Phone:216-749-8276
Mailing Address - Fax:216-749-8240
Practice Address - Street 1:1440 ROCKSIDE RD STE 202
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-2749
Practice Address - Country:US
Practice Address - Phone:216-749-8276
Practice Address - Fax:216-749-8240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 207RN0300X, 207RR0500X
OHNP09205363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2005145Medicaid
OHCD5577Medicare PIN
OH9288841Medicare PIN