Provider Demographics
NPI:1225023476
Name:BROWN, RYAN W (MPT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:W
Last Name:BROWN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 GANNETT DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6942
Mailing Address - Country:US
Mailing Address - Phone:207-773-0040
Mailing Address - Fax:
Practice Address - Street 1:119 GANNETT DR
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-6942
Practice Address - Country:US
Practice Address - Phone:207-773-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT3002225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME1398Medicare ID - Type UnspecifiedMEDICARE
ME061461OtherANTHEM BC/BS