=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578155594
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL JOHN RIEDER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2021
-----------------------------------------------------
Last Update Date | 02/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CHILDREN'S HOSPITAL 800 COMMISSIONER'S ROAD EAST
-----------------------------------------------------
City | LONDON
-----------------------------------------------------
State | ONTARIO
-----------------------------------------------------
Zip | N0M 1P0
-----------------------------------------------------
Country | CA
-----------------------------------------------------
Telephone | 519-685-8293
-----------------------------------------------------
Fax | 519-685-8156
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14773 THIRTEEN MILE ROAD
-----------------------------------------------------
City | DENFIELD
-----------------------------------------------------
State | ONTARIO
-----------------------------------------------------
Zip | N0M1P0
-----------------------------------------------------
Country | CA
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 4301402142
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------