Provider Demographics
NPI:1659305043
Name:RIDER, PAUL S (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:S
Last Name:RIDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1100 REID PARKWAY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374
Mailing Address - Country:US
Mailing Address - Phone:765-983-3127
Mailing Address - Fax:765-983-3219
Practice Address - Street 1:1434 CHESTER BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1947
Practice Address - Country:US
Practice Address - Phone:765-966-5527
Practice Address - Fax:765-966-5527
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01023981A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100256020OtherMANAGED HEALTH SERVICES
IN100256020Medicaid
IN00000082699OtherANTHEM
OH0651816Medicaid
IN351265355OtherTAX ID
IN351265355OtherTAX ID
IND95683Medicare UPIN
OH0651816Medicaid