1073052163 NPI number — MR. TIMOTHY RYAN RYSAVY PSYD, LP

Table of content: MR. TIMOTHY RYAN RYSAVY PSYD, LP (NPI 1073052163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073052163 NPI number — MR. TIMOTHY RYAN RYSAVY PSYD, LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RYSAVY
Provider First Name:
TIMOTHY
Provider Middle Name:
RYAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD, LP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073052163
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 230
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARTELL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56377-0230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-258-3833
Provider Business Mailing Address Fax Number:
320-253-5741

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
251 COUNTY ROAD 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST. CLOUD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56303-4872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-258-3833
Provider Business Practice Location Address Fax Number:
320-253-5741
Provider Enumeration Date:
02/22/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  LP6105 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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