Basic Information
| Provider Information | |||||||||
| NPI: | 1861443301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 801143 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641801143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733315583 | ||||||||
| FaxNumber: | 5733315079 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 SAINT FRANCIS DR | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637035049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733315770 | ||||||||
| FaxNumber: | 5733313974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 01/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 114168 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 204695217 | 05 | MO | MEDICAID | 110232380 | 01 | RAILROAD MEDICARE | OTHER | 152071 | 01 | BCBS | OTHER | 64069933 | 05 | KY | MEDICAID | 470335 | 01 | HEALTHLINK | OTHER |