Provider Demographics
NPI:1407885510
Name:RYAN, RONALD GARVIN (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:GARVIN
Last Name:RYAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5435 PROSPERITY CHURCH RD
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-1134
Mailing Address - Country:US
Mailing Address - Phone:704-863-9930
Mailing Address - Fax:704-863-9966
Practice Address - Street 1:5435 PROSPERITY CHURCH RD
Practice Address - Street 2:SUITE 1100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-1134
Practice Address - Country:US
Practice Address - Phone:704-863-9930
Practice Address - Fax:704-863-9966
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0072151207Q00000X
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905095Medicaid
NC5905095Medicaid
NC2059567Medicare ID - Type UnspecifiedCHUC PROSPERITY CROSSING
NC2059567AMedicare PIN