Provider Demographics
NPI:1205826393
Name:RYAN, TIMOTHY J
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:RYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 382
Mailing Address - Street 2:
Mailing Address - City:MEDFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02052-0382
Mailing Address - Country:US
Mailing Address - Phone:508-359-7229
Mailing Address - Fax:508-359-5363
Practice Address - Street 1:6 W MILL ST
Practice Address - Street 2:
Practice Address - City:MEDFIELD
Practice Address - State:MA
Practice Address - Zip Code:02052-1507
Practice Address - Country:US
Practice Address - Phone:508-359-7229
Practice Address - Fax:508-359-5363
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1813213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS026486OtherCHAMPUS
MA001813OtherTUFTS HEALTH PLAN
MA0002379OtherNEIGHBORHOOD HEALTH PLAN
MA0361771Medicaid
MA2704474OtherUNITED HEALTH CARE
MA33218OtherHARVARD PILGRIM HEALTH
MARYY70835OtherBLUE SHEILD OF MA
MARYY70835OtherBLUE SHEILD OF MA
MA001813OtherTUFTS HEALTH PLAN
MAS026486OtherCHAMPUS
MA480004926Medicare PIN