Basic Information
| Provider Information | |||||||||
| NPI: | 1912190455 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORAN | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1117 E HALLANDALE BEACH BLVD | ||||||||
| Address2: | |||||||||
| City: | HALLANDALE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330094488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544578771 | ||||||||
| FaxNumber: | 9549851434 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 JOHNSON ST | ||||||||
| Address2: | DIVISION OF PEDIATRIC CRITICAL CARE | ||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330215421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542656301 | ||||||||
| FaxNumber: | 9549851434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2007 | ||||||||
| LastUpdateDate: | 06/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | ME107350 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0203X | ME107350 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 002398200 | 05 | FL | MEDICAID |