Basic Information
| Provider Information | |||||||||
| NPI: | 1396736914 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREGORY | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 MALLORY LN | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370678233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153731350 | ||||||||
| FaxNumber: | 6152219054 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 BLANKENBAKER PKWY | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402431894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022530833 | ||||||||
| FaxNumber: | 5022530834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 11/04/2013 | ||||||||
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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 | 225100000X | PT7171 | TN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 5784 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 3659508 | 05 | TN | MEDICAID |