Provider Demographics
NPI:1033225024
Name:RYAN INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:RYAN INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:T
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-773-2560
Mailing Address - Street 1:107 E OAK AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1818
Mailing Address - Country:US
Mailing Address - Phone:928-773-2560
Mailing Address - Fax:928-913-8835
Practice Address - Street 1:107 E OAK AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1818
Practice Address - Country:US
Practice Address - Phone:928-773-2560
Practice Address - Fax:928-913-8835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22530207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F82069Medicare UPIN