Provider Demographics
NPI:1285726349
Name:RIDDICK, MEREDITH THOMAS (MD)
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:THOMAS
Last Name:RIDDICK
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 1:11660 ALPHARETTA HWY
Mailing Address - Street 2:SUITE 420
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4943
Mailing Address - Country:US
Mailing Address - Phone:770-442-5882
Mailing Address - Fax:770-664-6134
Practice Address - Street 1:11660 ALPHARETTA HWY
Practice Address - Street 2:SUITE 420
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4943
Practice Address - Country:US
Practice Address - Phone:770-442-5882
Practice Address - Fax:770-664-6134
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022269174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000244329FMedicaid
GA000244329FMedicaid