Provider Demographics
NPI:1083706501
Name:REIDER, JACOB M (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:M
Last Name:REIDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 ROUTE 9 STE A
Mailing Address - Street 2:
Mailing Address - City:HALFMOON
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3111
Mailing Address - Country:US
Mailing Address - Phone:518-900-1115
Mailing Address - Fax:
Practice Address - Street 1:1714 ROUTE 9 STE A
Practice Address - Street 2:
Practice Address - City:HALFMOON
Practice Address - State:NY
Practice Address - Zip Code:12065-3111
Practice Address - Country:US
Practice Address - Phone:518-900-1115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY201064207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01744843Medicaid
NY5634708OtherAETNA
NY08953OtherMVP
NY10021142OtherCDPHP
NY200150OtherSENIOR WHOLE HEALTH
NY000401055002OtherBSNENY
NY070315000059OtherFIDELIS
NY3686D1OtherEMPIRE BC
NY52560OtherGHI/HMO
NY08953OtherMVP
NY52560OtherGHI/HMO
NYG48550Medicare UPIN