Basic Information
| Provider Information | |||||||||
| NPI: | 1386679496 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602362 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043841775 | ||||||||
| FaxNumber: | 7043841776 | ||||||||
| Practice Location | |||||||||
| Address1: | 19485 OLD JETTON RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CORNELIUS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280316582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043841775 | ||||||||
| FaxNumber: | 7043841776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 04/01/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01023417 | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 200901870 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200307000A | 05 | IN | MEDICAID | 000000067648 | 01 | IN | ANTHEM BCBS | OTHER | 4255189 | 01 | AETNA | OTHER | 080162612 | 01 | MEDICARE RAILROAD | OTHER | 415089P | 01 | IN | SIHO | OTHER | 64022296 | 05 | KY | MEDICAID |