Provider Demographics
NPI:1902062755
Name:RYSCAVAGE, PATRICK AMADEUS (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:AMADEUS
Last Name:RYSCAVAGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-4613
Mailing Address - Fax:410-328-1112
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-4613
Practice Address - Fax:410-328-1112
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD72445207RI0200X, 2080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD550500300Medicaid
MD974690-01OtherCAREFIRST BC/BS
MDS062-0438OtherCAREFIRST BC/BS - REGIONAL
MD231066Y2ZMedicare PIN