1871865964 NPI number — MR. RYAN EDGAR GLOETZNER MOTR/L

Table of content: MR. RYAN EDGAR GLOETZNER MOTR/L (NPI 1871865964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871865964 NPI number — MR. RYAN EDGAR GLOETZNER MOTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLOETZNER
Provider First Name:
RYAN
Provider Middle Name:
EDGAR
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MOTR/L
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:
1871865964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4037 BROADVIEW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44286-9501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-615-4557
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5620 CLOVER PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDGEWOOD
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11385-6711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-615-4557
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/03/2012

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: 225X00000X , with the licence number:  017116 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: OT009151 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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