Healthcare Provider Details

I. General information

NPI: 1578155594
Provider Name (Legal Business Name): MICHAEL JOHN RIEDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CHILDREN'S HOSPITAL 800 COMMISSIONER'S ROAD EAST
LONDON ONTARIO
N0M 1P0
CA

IV. Provider business mailing address

14773 THIRTEEN MILE ROAD
DENFIELD ONTARIO
N0M1P0
CA

V. Phone/Fax

Practice location:
  • Phone: 519-685-8293
  • Fax: 519-685-8156
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301402142
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: