MEDICARE: TIMOTHY RYAN EDGAR IDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1002X	Independent Duty Corpsman	D6476308	CA

General Provider Information

NPI Number	:	1184059578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY RYAN EDGAR IDC

Provider Business Mailing Address
First Line	:	3883 INGRAHAM ST
Second Line	:	APT #U309
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-6433
Country	:	US
Telephone Number	:	559-975-5651
Fax Number	:

Provider Business Practice Location Address
First Line	:	3883 INGRAHAM ST
Second Line	:	APT #U309
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-6433
Country	:	US
Telephone Number	:	559-975-5651
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2013
Last Update Date	:	09/04/2013

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