1386679496 NPI number — MICHAEL G RYAN M.D.

Table of content: MICHAEL G RYAN M.D. (NPI 1386679496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386679496 NPI number — MICHAEL G RYAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RYAN
Provider First Name:
MICHAEL
Provider Middle Name:
G
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:
1386679496
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 602362
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-2362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-384-1775
Provider Business Mailing Address Fax Number:
704-384-1776

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19485 OLD JETTON RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CORNELIUS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28031-6582
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-384-1775
Provider Business Practice Location Address Fax Number:
704-384-1776
Provider Enumeration Date:
07/11/2006

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: 207Q00000X , with the licence number:  01023417 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 200901870 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200307000A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000067648 . This is a "ANTHEM BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 4255189 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 080162612 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 415089P . This is a "SIHO" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 64022296 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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