Provider Demographics
NPI:1326040783
Name:RYAN, COLLEEN E (MD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:E
Last Name:RYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:R
Other - Last Name:CORRODI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1350 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02081-1718
Mailing Address - Country:US
Mailing Address - Phone:508-668-2200
Mailing Address - Fax:508-668-6539
Practice Address - Street 1:1350 MAIN ST
Practice Address - Street 2:
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081-1718
Practice Address - Country:US
Practice Address - Phone:508-668-2200
Practice Address - Fax:508-668-6539
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA79455208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3125998Medicaid
36145OtherCMSP/HSP
9314935OtherCIGNA
4514287OtherAETNA/US HEALTHCARE
920717OtherAETNA/US HEALTHCARE HMO
79455OtherMEDICAL LIC
J14629OtherBCBS-MA
079455OtherTUFTS
200481OtherHPHC
3125998OtherMEDICAID-MA
P2967576OtherOXFORD
36145OtherCMSP/HSP