Provider Demographics
NPI:1346309275
Name:RYAN, KEVIN S (MPT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:S
Last Name:RYAN
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 1:30 GREAT RD STE 105
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-5684
Mailing Address - Country:US
Mailing Address - Phone:978-252-2800
Mailing Address - Fax:
Practice Address - Street 1:30 GREAT RD STE 105
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720
Practice Address - Country:US
Practice Address - Phone:978-252-2800
Practice Address - Fax:978-219-6200
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16058225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
613720OtherHARVARD PILGRIM
Y68110OtherBCBS
Y69013Medicare ID - Type Unspecified