Provider Demographics
NPI:1225076359
Name:RIEDERER, MARK FREDERICK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:FREDERICK
Last Name:RIEDERER
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 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST MEDICAL CENTER DR
Practice Address - Street 2:3RD FLOOR CS MOTT CHILDRENS HOSPITAL RECP C
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-4213
Practice Address - Country:US
Practice Address - Phone:734-936-5780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083195207X00000X, 208000000X, 2080S0010X
TN43020208000000X
PAMD4624842080S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep Medicine