Provider Demographics
NPI:1457394702
Name:NIEDER, HENRY S (MD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:S
Last Name:NIEDER
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:ONE HOSPITAL ROAD
Mailing Address - Street 2:P.O. BOX 1477
Mailing Address - City:OAK BLUFFS
Mailing Address - State:MA
Mailing Address - Zip Code:02557-1477
Mailing Address - Country:US
Mailing Address - Phone:508-693-0410
Mailing Address - Fax:508-693-5971
Practice Address - Street 1:ONE HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:OAK BLUFFS
Practice Address - State:MA
Practice Address - Zip Code:02557-1477
Practice Address - Country:US
Practice Address - Phone:508-693-0410
Practice Address - Fax:508-693-5971
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA59248207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3033112Medicaid
MA718897OtherTUFTS HEALTH
MA70181OtherHARVARD PILGRIM
A66550Medicare UPIN
MAJ07093Medicare ID - Type Unspecified