MEDICARE: MR. RYAN LEE THOMASON BA

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	1041S0200X	School Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316134968
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RYAN LEE THOMASON BA

Provider Business Mailing Address
First Line	:	114 ORCHARD LAKE RD
Second Line	:
City	:	PONTIAC
State	:	MI
Zip	:	48341-2244
Country	:	US
Telephone Number	:	248-858-7766
Fax Number	:	248-858-7201

Provider Business Practice Location Address
First Line	:	2351 W 12 MILE RD
Second Line	:
City	:	BERKLEY
State	:	MI
Zip	:	48072-1826
Country	:	US
Telephone Number	:	248-544-4006
Fax Number	:	248-544-4113

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

Provider Enumeration Date	:	09/27/2007
Last Update Date	:	09/27/2007

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