Provider Demographics
NPI:1821082801
Name:RADER, EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:RADER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35
Mailing Address - Street 2:
Mailing Address - City:NEWBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26410-0035
Mailing Address - Country:US
Mailing Address - Phone:304-892-2828
Mailing Address - Fax:304-892-2927
Practice Address - Street 1:30 CORTLAND ACRES LANE
Practice Address - Street 2:
Practice Address - City:THOMAS
Practice Address - State:WV
Practice Address - Zip Code:26292-9704
Practice Address - Country:US
Practice Address - Phone:304-463-3331
Practice Address - Fax:304-463-3338
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV15058207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0052162000Medicaid
WV2021133Medicare PIN
WV2021135Medicare PIN
B42733Medicare UPIN
WV080164775Medicare PIN
WV2021134Medicare PIN
WV2021131Medicare PIN
WV2021132Medicare PIN