Provider Demographics
NPI:1013192954
Name:JEFFREY G RIEDER DPM
Entity Type:Organization
Organization Name:JEFFREY G RIEDER DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:A
Authorized Official - Last Name:TANTALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-489-5550
Mailing Address - Street 1:1234 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PECKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18452-2043
Mailing Address - Country:US
Mailing Address - Phone:570-489-5550
Mailing Address - Fax:570-489-5958
Practice Address - Street 1:1234 MAIN ST
Practice Address - Street 2:
Practice Address - City:PECKVILLE
Practice Address - State:PA
Practice Address - Zip Code:18452-2043
Practice Address - Country:US
Practice Address - Phone:570-489-5550
Practice Address - Fax:570-489-5958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003897L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA5219630001Medicare NSC
PA758002Medicare PIN