Basic Information
Provider Information | |||||||||
NPI: | 1427149178 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RICHARDS | ||||||||
FirstName: | RYAN | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1055 N 500 W | ||||||||
Address2: | CREDENTIALING DEPARTMENT | ||||||||
City: | PROVO | ||||||||
State: | UT | ||||||||
PostalCode: | 846043305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013548225 | ||||||||
FaxNumber: | 8014180941 | ||||||||
Practice Location | |||||||||
Address1: | 1055 N 500 W STE 207 | ||||||||
Address2: |   | ||||||||
City: | PROVO | ||||||||
State: | UT | ||||||||
PostalCode: | 846043305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013754263 | ||||||||
FaxNumber: | 8014298085 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/27/2006 | ||||||||
LastUpdateDate: | 03/18/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/18/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 5924878-1205 | UT | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XS0106X | 5924878-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
ID | Type | State | Issuer | Description | 245449 | 01 | UT | ALTIUS | OTHER | 84628 | 01 | UT | PEHP | OTHER | 903371 | 01 | UT | DMBA | OTHER | 09-00576 | 01 | UT | UTAH HEALTHCARE | OTHER | P00293576 | 01 | UT | PALMETTO | OTHER | 870281028RR2 | 01 | UT | EMIA | OTHER | 107040000101 | 01 | UT | IHC | OTHER | D6299 | 05 | UT |   | MEDICAID |