Healthcare Provider Details

I. General information

NPI: 1659305043
Provider Name (Legal Business Name): PAUL S RIDER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 03/07/2023
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1434 CHESTER BLVD
RICHMOND IN
47374-1947
US

IV. Provider business mailing address

1100 REID PARKWAY MEDICAL STAFF SERVICES
RICHMOND IN
47374
US

V. Phone/Fax

Practice location:
  • Phone: 765-966-5527
  • Fax: 765-966-5527
Mailing address:
  • Phone: 765-983-3127
  • Fax: 765-983-3219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01023981A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: