1295765337 NPI number — LORETTA A RYAN M.D.

Table of content: LORETTA A RYAN M.D. (NPI 1295765337)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295765337 NPI number — LORETTA A RYAN M.D.

Organization/Personal Information

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

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:
1295765337
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1434 CHESTER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47374-1947
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-966-5527
Provider Business Mailing Address Fax Number:
765-966-5527

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1434 CHESTER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47374-1947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-966-5527
Provider Business Practice Location Address Fax Number:
765-966-5527
Provider Enumeration Date:
07/04/2006

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: 208000000X , with the licence number:  01048837A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200190240 . This is a "MANAGED HEALTH SERVICES" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 2178567 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200190240 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00000082701 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 351265355 . This is a "TAX ID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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