Active NPI
Brock Davis Ridenour, MD
- Plastic and Reconstructive Surgery Physician
- Saint Louis, MO
National Provider Identifier
1164536710
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Plastic and Reconstructive Surgery Physician
- License
- 101951
- Practice address
- 12460 Olive Blvd
Suite 202
Saint Louis, MO 63141-6409 - Phone
- (314) 909-1202
- Fax
- (314) 909-1290
- NPI assigned
- Aug 19, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Plastic and Reconstructive Surgery Physician | 2086S0122X | 101951 | MO | Primary |
Addresses
Primary practice location
12460 Olive Blvd
Suite 202
Saint Louis, MO 63141-6409
Mailing address
12460 Olive Blvd
Suite 202
Saint Louis, MO 63141-6409
Phone (314) 909-1202
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
- Opted out of Medicare
- Yes, effective Feb 27, 2017 through Feb 27, 2027
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 101951 | MO | MD | Plastic and Reconstructive Surgery Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1155945600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1164536710",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "12460 OLIVE BLVD",
"address_2": "SUITE 202",
"city": "SAINT LOUIS",
"state": "MO",
"postal_code": "631416409",
"telephone_number": "314-909-1202",
"fax_number": "314-909-1290"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12460 OLIVE BLVD",
"address_2": "SUITE 202",
"city": "SAINT LOUIS",
"state": "MO",
"postal_code": "631416409",
"telephone_number": "314-909-1202",
"fax_number": "314-909-1290"
}
],
"practiceLocations": [],
"basic": {
"last_name": "RIDENOUR",
"first_name": "BROCK",
"middle_name": "DAVIS",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-08-19",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "2086S0122X",
"taxonomy_group": "",
"desc": "Surgery, Plastic and Reconstructive Surgery",
"state": "MO",
"license": "101951",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Saint Louis, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.