Basic Information
| Provider Information | |||||||||
| NPI: | 1578822730 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANNICK | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 833 CHESTNUT ST STE 520 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2676064478 | ||||||||
| FaxNumber: | 2673393761 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 ENGLISH CREEK AVE STE 1300 | ||||||||
| Address2: | |||||||||
| City: | EGG HARBOR TOWNSHIP | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082345598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003219999 | ||||||||
| FaxNumber: | 2674791321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2012 | ||||||||
| LastUpdateDate: | 11/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 25MA10209400 | NJ | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 2081S0010X | MT201720 | PA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine | 390200000X | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2081S0010X | 25MA10209400 | NJ | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine |
No ID Information.