Basic Information
| Provider Information | |||||||||
| NPI: | 1538381074 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIVERMORE | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | WOODWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1923 N WEBB RD | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672063405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162624886 | ||||||||
| FaxNumber: | 3162624887 | ||||||||
| Practice Location | |||||||||
| Address1: | 1923 N WEBB RD | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162624886 | ||||||||
| FaxNumber: | 3162624887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 06/28/2018 | ||||||||
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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 | 207X00000X | 0431543 | KS | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200575660C | 05 | KS | MEDICAID | 111178025 | 01 | KS | PTAN | OTHER |