Basic Information
| Provider Information | |||||||||
| NPI: | 1811150733 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MICHAEL J. RYAN,DPM,PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RYAN FOOT & ANKLE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 HWY 49 SOUTH | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044552999 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8310 MEDICAL PLAZA DR STE E | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282626703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045480222 | ||||||||
| FaxNumber: | 7045481157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2008 | ||||||||
| LastUpdateDate: | 07/10/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RYAN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7044552999 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0807F | 01 | NC | BCBS0807F | OTHER |