Basic Information
Provider Information | |||||||||
NPI: | 1134188238 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RIDDLE | ||||||||
FirstName: | SAMUEL | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | III | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 743904 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303743904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8032967320 | ||||||||
FaxNumber: | 8032967330 | ||||||||
Practice Location | |||||||||
Address1: | 115 N SUMTER ST | ||||||||
Address2: | SUITE 200 | ||||||||
City: | SUMTER | ||||||||
State: | SC | ||||||||
PostalCode: | 291504972 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037758351 | ||||||||
FaxNumber: | 8037741512 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/20/2006 | ||||||||
LastUpdateDate: | 12/04/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 12846 | SC | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 128463 | 05 | SC |   | MEDICAID | C606127124 | 01 | SC | MEDICARE ID | OTHER |