Provider Demographics
NPI:1073585204
Name:RIDER, JOHN A (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:RIDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:7033 SAINT ANDREWS RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-1179
Mailing Address - Country:US
Mailing Address - Phone:803-376-2838
Mailing Address - Fax:803-407-1386
Practice Address - Street 1:7033 SAINT ANDREWS RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1179
Practice Address - Country:US
Practice Address - Phone:803-376-2838
Practice Address - Fax:803-407-1386
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC7395208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC073958Medicaid
SC073958Medicaid
SCB9137755738Medicare PIN