Provider Demographics
NPI:1144227711
Name:EDWARDS, RYAN D (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:D
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 W. FAIR AVENUE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2675
Mailing Address - Country:US
Mailing Address - Phone:906-225-3853
Mailing Address - Fax:906-228-4065
Practice Address - Street 1:1414 W. FAIR AVENUE
Practice Address - Street 2:SUITE 230
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-3853
Practice Address - Fax:906-228-4065
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRE070400208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E26017OtherBLUE CROSS/BLUE SHIELD
MI4462219Medicaid
MI0E26017OtherBLUE CROSS/BLUE SHIELD
H70384Medicare UPIN
MI0E26017Medicare ID - Type UnspecifiedMEDICARE
MIH70384Medicare UPIN