1083706501 NPI number — DR. JACOB M REIDER M.D.

Table of content: DR. JACOB M REIDER M.D. (NPI 1083706501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083706501 NPI number — DR. JACOB M REIDER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REIDER
Provider First Name:
JACOB
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083706501
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1714 ROUTE 9 STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HALFMOON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12065-3111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-900-1115
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1714 ROUTE 9 STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HALFMOON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12065-3111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-900-1115
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  201064 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01744843 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5634708 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 08953 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10021142 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 200150 . This is a "SENIOR WHOLE HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000401055002 . This is a "BSNENY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 070315000059 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 3686D1 . This is a "EMPIRE BC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 52560 . This is a "GHI/HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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