Ridge Lake ASC, LLC

Primary specialty

Ophthalmologic Surgery Clinic/CenterTaxonomy code 261QS0132X

License

0000000049 Issued in TN

Legal business name

RIDGE LAKE ASC, LLC

Practice address

825 Ridge Lake Blvd
Memphis, TN 38120-9411

Phone

(901) 685-2200

Fax

(901) 820-2342

NPI assigned

Dec 8, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Subba R Gollamudi, MD

Title

Managing Partner

Phone

(901) 685-2200

Specialties & licenses 2

Addresses

Other identifiers 3

Listed as

Ridge Lake ASC LLCCCN 44C0001016

Medicare certification status

ActiveFrom the Provider of Services file

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1165536000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658707200000",
    "number": "1790844132",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "825 RIDGE LAKE BLVD",
            "city": "MEMPHIS",
            "state": "TN",
            "postal_code": "381209411",
            "telephone_number": "901-685-2200",
            "fax_number": "901-820-2342"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "825 RIDGE LAKE BLVD",
            "city": "MEMPHIS",
            "state": "TN",
            "postal_code": "381209411",
            "telephone_number": "901-685-2200",
            "fax_number": "901-820-2342"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RIDGE LAKE ASC, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-08",
        "last_updated": "2022-07-25",
        "certification_date": "2022-07-25",
        "status": "A",
        "authorized_official_last_name": "GOLLAMUDI",
        "authorized_official_first_name": "SUBBA",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "MANAGING PARTNER",
        "authorized_official_telephone_number": "901-685-2200",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": "TN",
            "license": "0000000049",
            "primary": false
        },
        {
            "code": "261QS0132X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ophthalmologic Surgery",
            "state": "TN",
            "license": "0000000049",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "Q016777",
            "state": "TN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00074013",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "190552128",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Jennifer Lynn Riddle
• Mallory Lynn Riddle, DPT
• Ronisha Riddlespriger
• Pamela C Rideout
• Ridge Lake Anesthesia
• Ridgemont Manor, Inc
• Tracee Ridley-Pryor, DNP
• Samantha Rieben, RBT
• Allison Marie Rieman, MS, LMFT
• Martha D Rieman, RN/NP

• Ophthalmologic Surgery Clinic/Center in Memphis, TN
• Providers in Memphis, TN by specialty
• Ophthalmologic Surgery Clinic/Center in Tennessee

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 25, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.