Basic Information
| Provider Information | |||||||||
| NPI: | 1811953805 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHARBENEAU | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7000 NORTH MOPAC | ||||||||
| Address2: | SUITE #420 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124820045 | ||||||||
| FaxNumber: | 5124769892 | ||||||||
| Practice Location | |||||||||
| Address1: | 7000 NORTH MOPAC | ||||||||
| Address2: | SUITE #420 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124820045 | ||||||||
| FaxNumber: | 5124769892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 02/14/2014 | ||||||||
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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 | 207R00000X | M6526 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | M6562 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | P00295142 | 01 | MI | RR MEDICARE | OTHER | 189856101 | 05 | TX | MEDICAID | 104833504 | 05 | MI | MEDICAID |