Provider Demographics
NPI:1437145091
Name:CRIDER, JACK BYRON (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:BYRON
Last Name:CRIDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:387 TOWN MOUNTAIN RD
Mailing Address - Street 2:STE 202
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-1640
Mailing Address - Country:US
Mailing Address - Phone:606-437-1008
Mailing Address - Fax:606-437-5040
Practice Address - Street 1:387 TOWN MOUNTAIN RD
Practice Address - Street 2:STE 202
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1640
Practice Address - Country:US
Practice Address - Phone:606-437-1008
Practice Address - Fax:606-437-5040
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY35982208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64031610Medicaid
WV1812140000Medicaid