Basic Information
| Provider Information | |||||||||
| NPI: | 1053644179 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | BOGEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 85 S WEST ST | ||||||||
| Address2: | |||||||||
| City: | HOMER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130771542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077533797 | ||||||||
| FaxNumber: | 6077536677 | ||||||||
| Practice Location | |||||||||
| Address1: | 23 CENTRAL ST | ||||||||
| Address2: | |||||||||
| City: | MORAVIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131187709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154979066 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2009 | ||||||||
| LastUpdateDate: | 09/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 272489 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03802068 | 05 | NY | MEDICAID |