Basic Information
| Provider Information | |||||||||
| NPI: | 1659337525 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIDER | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | KEVIN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976306 | ||||||||
| FaxNumber: | 8647976198 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 N FANT ST | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296215708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645121335 | ||||||||
| FaxNumber: | 8645128575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 19706 | SC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | T37332 | 05 | SC | MEDICAID | 595784016A | 05 | GA | MEDICAID | P00177247 | 01 | SC | RAILROAD MEDICARE | OTHER | 5901116 | 05 | NC | MEDICAID |