Provider Demographics
NPI:1043664899
Name:MATHEW, RYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:MATHEW
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 1:4280 WATERMELON RD
Mailing Address - Street 2:STE 112
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473-5250
Mailing Address - Country:US
Mailing Address - Phone:205-464-4975
Mailing Address - Fax:205-750-0855
Practice Address - Street 1:4280 WATERMELON RD STE 112
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35473-5250
Practice Address - Country:US
Practice Address - Phone:205-750-0030
Practice Address - Fax:205-750-0855
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.068511207R00000X
AL44728207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1043664899Medicaid