Provider Demographics
NPI:1083854574
Name:KEITH A RYAN MD PC
Entity Type:Organization
Organization Name:KEITH A RYAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-235-4020
Mailing Address - Street 1:2510 E 15TH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1233 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2926
Practice Address - Country:US
Practice Address - Phone:307-577-7201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-24
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7118A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY120997300Medicaid
WY313512OtherBLUE CROSS BLUE SHEILD OF WYOMING
W22581Medicare PIN