Basic Information
Provider Information | |||||||||
NPI: | 1679667513 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RYAN | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 NORTH ST | ||||||||
Address2: | SUITE 101 | ||||||||
City: | GENEVA | ||||||||
State: | NY | ||||||||
PostalCode: | 144561561 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157875100 | ||||||||
FaxNumber: | 3157875108 | ||||||||
Practice Location | |||||||||
Address1: | 200 NORTH ST | ||||||||
Address2: | SUITE 101 | ||||||||
City: | GENEVA | ||||||||
State: | NY | ||||||||
PostalCode: | 144561561 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157875100 | ||||||||
FaxNumber: | 3157875108 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2006 | ||||||||
LastUpdateDate: | 06/28/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 164272 | NY | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1072637 | 05 | NY |   | MEDICAID | 164272-7 | 01 | NY | WORKERS COMP | OTHER | 102496BJ | 01 | NY | PREFERRED CARE | OTHER | P00003457 | 01 | NY | R.R. MEDICARE | OTHER | 2593569 | 01 | NY | GHI | OTHER | P010164272 | 01 | NY | BLUE CROSS | OTHER |