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General NPI Number Information
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NPI Number | 1437145091
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Entity Type | Individual
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Provider Name | JACK BYRON CRIDER M.D.
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Gender | Male
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Dates
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Enumeration Date | 09/20/2005
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Last Update Date | 06/12/2013
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Provider Practice Location Address
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Address Line | 387 TOWN MOUNTAIN RD STE 202
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City | PIKEVILLE
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State | KY
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Zip | 41501-1640
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Country | US
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Telephone | 606-437-1008
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Fax | 606-437-5040
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Provider Business Mailing Address
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Address Line | 387 TOWN MOUNTAIN RD STE 202
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City | PIKEVILLE
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State | KY
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Zip | 41501-1640
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Country | US
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Telephone | 606-437-1008
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Fax | 606-437-5040
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 35982
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License Number State | KY
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