Basic Information
| Provider Information | |||||||||
| NPI: | 1114380433 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUTHERLAND | ||||||||
| FirstName: | RYAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 S GREENE ST | ||||||||
| Address2: | DEPT OF RADIOLOGY | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103283477 | ||||||||
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| Practice Location | |||||||||
| Address1: | 22 S GREENE ST | ||||||||
| Address2: | DEPT OF RADIOLOGY | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103283477 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2016 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | D85885 | MD | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 008656800 | 05 | MD | MEDICAID | 039918288 | 05 | DC | MEDICAID |