Healthcare Provider Details

I. General information

NPI: 1669444865
Provider Name (Legal Business Name): THOMAS RYDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 05/02/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USAMEDDAC FORT MEADE 2481 LLEWELLYN AVENUE
FORT GEORGE G MEADE MD
20755
US

IV. Provider business mailing address

32 CATIN AVE
QUANTICO VA
22134
US

V. Phone/Fax

Practice location:
  • Phone: 703-696-3440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD067522L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: