Basic Information
| Provider Information | |||||||||
| NPI: | 1700837259 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REDER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5010 | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587025010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018575650 | ||||||||
| FaxNumber: | 7018575031 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 21ST AVE SE | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587016256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018577387 | ||||||||
| FaxNumber: | 7018577831 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 12/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 22501 | SC | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 225018 | 05 | SC | MEDICAID |