Provider Demographics
NPI:1073213815
Name:SYRIANOUDIS, FIDEL RYAN
Entity Type:Individual
Prefix:
First Name:FIDEL
Middle Name:RYAN
Last Name:SYRIANOUDIS
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 1:5400 REVERE RUN
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-8678
Mailing Address - Country:US
Mailing Address - Phone:234-567-1107
Mailing Address - Fax:
Practice Address - Street 1:2400 NILES CORTLAND RD SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-3869
Practice Address - Country:US
Practice Address - Phone:330-652-4222
Practice Address - Fax:330-652-0574
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.025775225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist