Provider Demographics
NPI:1043772627
Name:KELM, RYAN CHAR
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:CHAR
Last Name:KELM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 LOMASNEY WAY APT 310
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-1537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 STANIFORD ST # 250
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2517
Practice Address - Country:US
Practice Address - Phone:617-724-6960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36.161422207N00000X
390200000X
IL125.074341207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program