Provider Demographics
NPI:1326036617
Name:RIDER, BROOKELLEN (DO)
Entity Type:Individual
Prefix:
First Name:BROOKELLEN
Middle Name:
Last Name:RIDER
Suffix:
Gender:F
Credentials:DO
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 49
Mailing Address - Street 2:400 EASTERN SHORE DRIVE
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804
Mailing Address - Country:US
Mailing Address - Phone:410-749-0821
Mailing Address - Fax:410-219-5662
Practice Address - Street 1:314 FRANKLIN AVE
Practice Address - Street 2:SUITE 403
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811
Practice Address - Country:US
Practice Address - Phone:410-629-1995
Practice Address - Fax:410-629-1993
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0044828207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD483791600Medicaid
MDF58285Medicare UPIN
MD843M537FMedicare ID - Type Unspecified