Provider Demographics
NPI:1346289402
Name:CONRAD, RYAN SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:SCOTT
Last Name:CONRAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RYAN
Other - Middle Name:SCOTT
Other - Last Name:CONRAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1845
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-1845
Mailing Address - Country:US
Mailing Address - Phone:704-662-3077
Mailing Address - Fax:704-662-3458
Practice Address - Street 1:124 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE C
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5609
Practice Address - Country:US
Practice Address - Phone:704-662-3077
Practice Address - Fax:704-662-3458
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC009000335174400000X
NC2005-013162084N0400X
NC2015-013162084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901715Medicaid
NCNCF200AMedicare PIN
NC5901715Medicaid