Healthcare Provider Details

I. General information

NPI: 1639592678
Provider Name (Legal Business Name): TIMOTHY RYDER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2014
Last Update Date: 01/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 DESALES AVE
CHATTANOOGA TN
37404-1161
US

IV. Provider business mailing address

2525 DESALES AVE
CHATTANOOGA TN
37404-1161
US

V. Phone/Fax

Practice location:
  • Phone: 423-493-6401
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number18283
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: