Provider Demographics
NPI:1992718175
Name:RIDLEY, CHARLES L III (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
Last Name:RIDLEY
Suffix:III
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 1:2266 INGLESIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2032
Mailing Address - Country:US
Mailing Address - Phone:478-745-6050
Mailing Address - Fax:
Practice Address - Street 1:2266 INGLESIDE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-2032
Practice Address - Country:US
Practice Address - Phone:478-745-6050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025476207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA279620OtherBLUE CROSS BLUE SHIELD
GA279620OtherBLUE CROSS BLUE SHIELD