Provider Demographics
NPI:1437103561
Name:RYAN, JOHN BLAICH (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BLAICH
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 1:132 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-1829
Mailing Address - Country:US
Mailing Address - Phone:315-258-8282
Mailing Address - Fax:315-258-7386
Practice Address - Street 1:132 NORTH ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-1829
Practice Address - Country:US
Practice Address - Phone:315-258-8282
Practice Address - Fax:315-258-7386
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179142208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01412968Medicaid
NY01412968Medicaid
NYBB1227Medicare ID - Type Unspecified