MEDICARE: MARK REIDER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor		MI

General Provider Information

NPI Number	:	1114320595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK REIDER

Provider Business Mailing Address
First Line	:	3944 GRAND HAVEN RD. APT. 204C
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49441
Country	:	US
Telephone Number	:	231-725-5487
Fax Number	:

Provider Business Practice Location Address
First Line	:	3944 GRAND HAVEN RD APT 204C
Second Line	:
City	:	NORTON SHORES
State	:	MI
Zip	:	49441
Country	:	US
Telephone Number	:	231-725-5487
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2014
Last Update Date	:	10/02/2014

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