1790989663 NPI number — WILLIAM RYAN SUTHERLAND M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790989663 NPI number — WILLIAM RYAN SUTHERLAND M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUTHERLAND
Provider First Name:
WILLIAM
Provider Middle Name:
RYAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790989663
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 936
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONDON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40743-0936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
606-330-7825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
227 FALCON DR STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MT STERLING
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40353-9792
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-497-5160
Provider Business Practice Location Address Fax Number:
859-497-5166
Provider Enumeration Date:
06/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  43004 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208600000X , with the licence number: 01063074A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200869500A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100089710 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200869500T , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0816010001 . This is a "DMERC" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00642704 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000526049 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".




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