Provider Demographics
NPI:1700010964
Name:GUADALUPE FAMILY HEALTH, PA
Entity Type:Organization
Organization Name:GUADALUPE FAMILY HEALTH, PA
Other - Org Name:DAVID M. RIDER, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:RIDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-379-7901
Mailing Address - Street 1:PO BOX 1206
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78156-1206
Mailing Address - Country:US
Mailing Address - Phone:830-379-7901
Mailing Address - Fax:830-401-0437
Practice Address - Street 1:1414 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-5175
Practice Address - Country:US
Practice Address - Phone:830-379-7901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-04
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8283207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2089765-01Medicaid
TX0076SKOtherBLUE CROSS BLUE SHIELD ID #
TX2089765-02OtherMEDICAID FOR TEXAS HEALTH STEPS
TX0A4671Medicare PIN