Provider Demographics
NPI:1245244649
Name:RIDER, RUSSELL E (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:E
Last Name:RIDER
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:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:LONG LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12847-0129
Mailing Address - Country:US
Mailing Address - Phone:518-624-2301
Mailing Address - Fax:518-624-2043
Practice Address - Street 1:8561 NEWCOMB RD
Practice Address - Street 2:
Practice Address - City:LONG LAKE
Practice Address - State:NY
Practice Address - Zip Code:12847-0129
Practice Address - Country:US
Practice Address - Phone:518-624-2301
Practice Address - Fax:518-624-2043
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1712651207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01110874Medicaid
E15685Medicare UPIN
NY53283AMedicare PIN
NY01110874Medicaid