Provider Demographics
NPI:1730183526
Name:RYSCHON, TIMOTHY WAYNE (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:RYSCHON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 PORTOFINO DR STE 2106
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32561-2503
Mailing Address - Country:US
Mailing Address - Phone:720-206-7058
Mailing Address - Fax:866-614-6108
Practice Address - Street 1:2 PORTOFINO DR STE 2107
Practice Address - Street 2:
Practice Address - City:PENSACOLA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32561-2503
Practice Address - Country:US
Practice Address - Phone:720-206-7058
Practice Address - Fax:866-614-6108
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN67784207P00000X
AZ44159208000000X
CO43417207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ611583Medicaid
CO02783533Medicaid
COST10/20/10Medicare PIN