Healthcare Provider Details

I. General information

NPI: 1639157266
Provider Name (Legal Business Name): EDWARD RYDZAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 02/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1139 LEXINGTON AVE
SAVANNAH GA
31404-5502
US

IV. Provider business mailing address

1139 LEXINGTON AVE
SAVANNAH GA
31404-5502
US

V. Phone/Fax

Practice location:
  • Phone: 912-303-4200
  • Fax: 912-790-2701
Mailing address:
  • Phone: 912-303-4200
  • Fax: 912-790-2701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number038941
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000623059F
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 2
Identifier11BDSLT
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerMEDICARE PTAN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: