Healthcare Provider Details

I. General information

NPI: 1083613186
Provider Name (Legal Business Name): EDWARD A RYAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 10/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 MAIN ST STE 108
WINCHESTER MA
01890-1961
US

IV. Provider business mailing address

340 MAIN ST STE. 670
WORCESTER MA
01608-1604
US

V. Phone/Fax

Practice location:
  • Phone: 787-721-0447
  • Fax: 781-721-2250
Mailing address:
  • Phone: 508-754-3566
  • Fax: 508-438-6368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number71171
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: