Provider Demographics
NPI:1023000882
Name:RYAN, JOHN B (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:RYAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11012 E 13 MILE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2547
Mailing Address - Country:US
Mailing Address - Phone:586-582-0864
Mailing Address - Fax:586-582-0964
Practice Address - Street 1:11012 E 13 MILE RD STE 201
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2547
Practice Address - Country:US
Practice Address - Phone:586-582-0864
Practice Address - Fax:586-582-0964
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068798207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4528910Medicaid
MIJR068798OtherBCBS PIN #
MIJR068798OtherBCBS PIN #
MI0E06376019Medicare PIN