Healthcare Provider Details

I. General information

NPI: 1831779065
Provider Name (Legal Business Name): EMILY KATHERINE RIDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12576 WINFIELD RD
WINFIELD WV
25213-7315
US

IV. Provider business mailing address

12576 WINFIELD RD
WINFIELD WV
25213-7315
US

V. Phone/Fax

Practice location:
  • Phone: 304-586-0112
  • Fax: 304-586-0114
Mailing address:
  • Phone: 304-586-0112
  • Fax: 304-586-0114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4295
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: