Basic Information
| Provider Information | |||||||||
| NPI: | 1730210089 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CALDWELL | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | BLAINE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601643 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048636241 | ||||||||
| FaxNumber: | 7043555948 | ||||||||
| Practice Location | |||||||||
| Address1: | 8800 NORTH TRYON STREET | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282623300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048636241 | ||||||||
| FaxNumber: | 7043555948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 29018 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 2009-01380 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1730210089 | 05 | NC | MEDICAID | 5912204 | 05 | NC | MEDICAID | N0138A | 05 | SC | MEDICAID |