Provider Demographics
NPI:1528688249
Name:RIDDELL, MADYSON SHEA (DO)
Entity type:Individual
Prefix:DR
First Name:MADYSON
Middle Name:SHEA
Last Name:RIDDELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7103 RED BARN RD
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-1056
Mailing Address - Country:US
Mailing Address - Phone:815-353-2513
Mailing Address - Fax:
Practice Address - Street 1:4201 ST. ANTOINE
Practice Address - Street 2:SUITE 6C UHC
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-577-5009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program