Basic Information
Provider Information | |||||||||
NPI: | 1457394702 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NIEDER | ||||||||
FirstName: | HENRY | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | ONE HOSPITAL ROAD | ||||||||
Address2: | P.O. BOX 1477 | ||||||||
City: | OAK BLUFFS | ||||||||
State: | MA | ||||||||
PostalCode: | 025571477 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5086930410 | ||||||||
FaxNumber: | 5086935971 | ||||||||
Practice Location | |||||||||
Address1: | ONE HOSPITAL ROAD | ||||||||
Address2: |   | ||||||||
City: | OAK BLUFFS | ||||||||
State: | MA | ||||||||
PostalCode: | 025571477 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5086930410 | ||||||||
FaxNumber: | 5086935971 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2006 | ||||||||
LastUpdateDate: | 07/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 59248 | MA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 3033112 | 05 | MA |   | MEDICAID | 718897 | 01 | MA | TUFTS HEALTH | OTHER | 70181 | 01 | MA | HARVARD PILGRIM | OTHER |