Healthcare Provider Details

I. General information

NPI: 1881783413
Provider Name (Legal Business Name): EDWARD P TYSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3811 BEE CAVES RD STE 200
AUSTIN TX
78746-6459
US

IV. Provider business mailing address

3811 BEE CAVES RD STE 200
AUSTIN TX
78746-6459
US

V. Phone/Fax

Practice location:
  • Phone: 512-380-9999
  • Fax: 512-380-0072
Mailing address:
  • Phone: 512-380-9999
  • Fax: 512-380-0072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberG3873
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: