Mal S Riddell, D.O. Clinic

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

08590 Issued in MS

Legal business name

MAL S RIDDELL, D.O. CLINIC

Practice address

1300 Sunset Dr
Suite B
Grenada, MS 38901-4086

Phone

(662) 226-6430

Fax

(662) 226-0018

NPI assigned

Aug 20, 2009

Organization subpart

No

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

Authorized official

Name

Dr. Mal S Riddell III, D.O.

Title

Owner

Phone

(662) 226-6430

Specialties & licenses 1

Addresses

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

{
    "created_epoch": "1250726400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1483660800000",
    "number": "1962634170",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1300 SUNSET DR",
            "address_2": "SUITE B",
            "city": "GRENADA",
            "state": "MS",
            "postal_code": "389014086",
            "telephone_number": "662-226-6430",
            "fax_number": "662-226-0018"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1300 SUNSET DR",
            "address_2": "SUITE B",
            "city": "GRENADA",
            "state": "MS",
            "postal_code": "389014086",
            "telephone_number": "662-226-6430",
            "fax_number": "662-226-0018"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAL S RIDDELL, D.O. CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-08-20",
        "last_updated": "2017-01-06",
        "status": "A",
        "authorized_official_last_name": "RIDDELL",
        "authorized_official_first_name": "MAL",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "662-226-6430",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_name_suffix": "III",
        "authorized_official_credential": "D.O."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "MS",
            "license": "08590",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Family Medicine Physician in Grenada, MS
• Providers in Grenada, MS by specialty
• Family Medicine Physician in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 6, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.