Provider Demographics
NPI:1245378413
Name:RIEDEL, ALICE R (MD)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:R
Last Name:RIEDEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:520 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:MO
Practice Address - Zip Code:65781-9200
Practice Address - Country:US
Practice Address - Phone:417-742-2300
Practice Address - Fax:417-742-2335
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2004025508207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208373506Medicaid
MOI23481Medicare UPIN
MOPENDINGMedicare PIN