Provider Demographics
NPI:1326129065
Name:RIDER, LYNN ALAN
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:ALAN
Last Name:RIDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:ALAN
Other - Last Name:RIDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:11301 YOUNGSTOUN DR
Mailing Address - Street 2:APT 1408
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-8103
Mailing Address - Country:US
Mailing Address - Phone:301-791-5549
Mailing Address - Fax:
Practice Address - Street 1:363 S CLEVELAND AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5747
Practice Address - Country:US
Practice Address - Phone:301-790-1100
Practice Address - Fax:301-797-6307
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0027340174400000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDAR1441788OtherDEA
MDAR1441788OtherDEA
MDK864CE65Medicare PIN