Provider Demographics
NPI:1386679496
Name:RYAN, MICHAEL G (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:RYAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2362
Mailing Address - Country:US
Mailing Address - Phone:704-384-1775
Mailing Address - Fax:704-384-1776
Practice Address - Street 1:19485 OLD JETTON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-6582
Practice Address - Country:US
Practice Address - Phone:704-384-1775
Practice Address - Fax:704-384-1776
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01023417207Q00000X
NC200901870207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200307000AMedicaid
IN000000067648OtherANTHEM BCBS
4255189OtherAETNA
080162612OtherMEDICARE RAILROAD
IN415089POtherSIHO
KY64022296Medicaid
D67269Medicare UPIN
4255189OtherAETNA
IN200307000AMedicaid
KY64022296Medicaid