Provider Demographics
NPI:1861810954
Name:RIDLEY, ERICA KRISTEN (MD)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:KRISTEN
Last Name:RIDLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:KRISTEN
Other - Last Name:GRANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:16801 NEWBURGH RD STE 106
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-1606
Mailing Address - Country:US
Mailing Address - Phone:734-591-6660
Mailing Address - Fax:734-744-8514
Practice Address - Street 1:16801 NEWBURGH RD STE 106
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1606
Practice Address - Country:US
Practice Address - Phone:734-591-6660
Practice Address - Fax:734-744-8514
Is Sole Proprietor?:No
Enumeration Date:2014-04-04
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105077207R00000X
390200000X
MI4301500514207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICV0022635Medicaid