1700863511 NPI number — MR. MICHAEL J RYAN M.D

Table of content: (NPI 1750587598)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700863511 NPI number — MR. MICHAEL J RYAN M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RYAN
Provider First Name:
MICHAEL
Provider Middle Name:
J
Provider Name Prefix Text:
MR.
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:
1700863511
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1428 PHILLIPS LN STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN LUIS OBISPO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93401-2551
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-543-4407
Provider Business Mailing Address Fax Number:
805-543-4587

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1428 PHILLIPS LN STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN LUIS OBISPO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93401-2551
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-543-4407
Provider Business Practice Location Address Fax Number:
805-543-4587
Provider Enumeration Date:
12/22/2005

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: 207R00000X , with the licence number:  A86911 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: A86911 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: A86911 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1700863511 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: PAR . This is a "MULTIPLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: -029 . This is a "TRICARE/CHAMPUS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "VA PREMIER HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "VA HEALTH NETWORK" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7221858 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "USA MANAGED CARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "FIRST HEALTH COMMERCIAL" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2174181 . This is a "UHC/MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: WA86911A , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5908329 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6125139 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 08329 . This is a "NC BC/BS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 10025471 . This is a "SENTARA/OPTIMA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 342182 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7221858 . This is a "AETNA PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "CORVEL/CORECARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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