Provider Demographics
NPI:1407019862
Name:EDMONDS, RYANE ALEXANDRA (MD)
Entity Type:Individual
Prefix:
First Name:RYANE
Middle Name:ALEXANDRA
Last Name:EDMONDS
Suffix:
Gender:F
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:PO BOX 758963
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-8963
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:1110 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1602
Practice Address - Country:US
Practice Address - Phone:443-351-3917
Practice Address - Fax:443-351-3918
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD70531207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD320967YVZ - 945LMedicare PIN
MD320967ZDDB - 149619Medicare PIN