Provider Demographics
NPI:1467443879
Name:RYAN, CORY M (MD)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:M
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 1:166 HOSPITAL ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-2416
Mailing Address - Country:US
Mailing Address - Phone:606-348-9343
Mailing Address - Fax:606-340-3258
Practice Address - Street 1:166 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-2416
Practice Address - Country:US
Practice Address - Phone:606-348-9343
Practice Address - Fax:606-340-3258
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38039207P00000X, 207R00000X, 208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000545017OtherANTHEM BC & BS
KY1467443879OtherNPI
KY64059199Medicaid
KY0340OtherMEDICARE GROUP
KY3334428Medicare PIN
KY000000545017OtherANTHEM BC & BS
KY64059199Medicaid