Basic Information
| Provider Information | |||||||||
| NPI: | 1366726846 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYERS | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | BRUCE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CREDIT UNION WAY FL 3 | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023684633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819613370 | ||||||||
| FaxNumber: | 7819611291 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 LONGWATER DR STE 109 | ||||||||
| Address2: | |||||||||
| City: | NORWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020611620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3397889202 | ||||||||
| FaxNumber: | 3397889672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2011 | ||||||||
| LastUpdateDate: | 06/03/2019 | ||||||||
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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 | 261QP2000X | 19626 | MA | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 225100000X | 19626 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1222471 | 01 | MA | ASH/CIGNA | OTHER | 795050 | 01 | MA | OPTUM/UHC | OTHER | 9560858 | 01 | MA | AETNA | OTHER | 110094254A | 05 | MA | MEDICAID |