Basic Information
| Provider Information | |||||||||
| NPI: | 1588616510 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYDER | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 SAMARITAN DR | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301431964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062534673 | ||||||||
| FaxNumber: | 4043515983 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 J.L. WHITE DRIVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | JASPER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301434894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066366500 | ||||||||
| FaxNumber: | 7066366502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 07/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 119559 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 068550 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 00586567 | 05 | NY | MEDICAID | 003128026A | 05 | GA | MEDICAID |