Provider Demographics
NPI:1427432632
Name:RIDER, ROBERT LAWRENCE (PHD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LAWRENCE
Last Name:RIDER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:473 KING OF PRUSSIA RD
Mailing Address - Street 2:
Mailing Address - City:RADNOR
Mailing Address - State:PA
Mailing Address - Zip Code:19087-4518
Mailing Address - Country:US
Mailing Address - Phone:267-304-2069
Mailing Address - Fax:
Practice Address - Street 1:4050 S 26TH ST
Practice Address - Street 2:SUITE 140
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19112-1613
Practice Address - Country:US
Practice Address - Phone:267-463-2284
Practice Address - Fax:267-468-2301
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017874103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103062378Medicaid
PA103062378Medicaid