Provider Demographics
NPI:1194984443
Name:NYDEREK, PHIL JAMES SR
Entity type:Individual
Prefix:
First Name:PHIL
Middle Name:JAMES
Last Name:NYDEREK
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 ASHMOORE DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREENUP
Mailing Address - State:KY
Mailing Address - Zip Code:41144
Mailing Address - Country:US
Mailing Address - Phone:740-821-6973
Mailing Address - Fax:606-473-1389
Practice Address - Street 1:103 ASHMOORE DRIVE
Practice Address - Street 2:
Practice Address - City:GREENUP
Practice Address - State:KY
Practice Address - Zip Code:41144
Practice Address - Country:US
Practice Address - Phone:740-821-6973
Practice Address - Fax:606-473-1389
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2778632Medicaid