Basic Information
| Provider Information | |||||||||
| NPI: | 1922168947 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LITTLE DOC RIDER PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1578 | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218115578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106419450 | ||||||||
| FaxNumber: | 4106419515 | ||||||||
| Practice Location | |||||||||
| Address1: | 314 FRANKLIN AVE | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218111215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106291995 | ||||||||
| FaxNumber: | 4106291993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 12/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | RIDER | ||||||||
| AuthorizedOfficialFirstName: | BROOKELLEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROPRIETOR | ||||||||
| AuthorizedOfficialTelephone: | 4106291995 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.