Provider Demographics
NPI:1790216273
Name:CRIDER, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:CRIDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 WARDS CORNER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-6966
Mailing Address - Country:US
Mailing Address - Phone:513-576-7700
Mailing Address - Fax:513-576-1020
Practice Address - Street 1:1231 COLUMBUS AVE UNIT A1
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-8196
Practice Address - Country:US
Practice Address - Phone:513-695-4495
Practice Address - Fax:513-228-1236
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34016113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program