Basic Information
| Provider Information | |||||||||
| NPI: | 1043320138 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | DONALD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 COLLINS DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CARTERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301202486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706070795 | ||||||||
| FaxNumber: | 7706071339 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 COLLINS DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CARTERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301202486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706070795 | ||||||||
| FaxNumber: | 7706071339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 042415 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 002618 | 01 | GA | BCBSGA | OTHER | 10032515 | 01 | GA | AMERIGROUP | OTHER | 12-01508 | 01 | GA | UNITED HEALTH CARE | OTHER | 303401 | 01 | GA | WELLCARE OF GA | OTHER | 5925435 | 01 | GA | CIGNA | OTHER |