Basic Information
| Provider Information | |||||||||
| NPI: | 1417458985 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | ERIC | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 FAIRMOUNT AVE STE 302 | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212865494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109278768 | ||||||||
| FaxNumber: | 4106484878 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 W 40TH ST STE 352 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212112100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102435399 | ||||||||
| FaxNumber: | 4102435366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2018 | ||||||||
| LastUpdateDate: | 02/21/2018 | ||||||||
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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 | 26877 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.