Provider Demographics
NPI:1659356905
Name:RYAN, KATHLEEN L (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:L
Last Name:RYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 ARK RD
Mailing Address - Street 2:STE 206 LMC I
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-3100
Mailing Address - Country:US
Mailing Address - Phone:856-778-4640
Mailing Address - Fax:856-778-8862
Practice Address - Street 1:204 ARK RD
Practice Address - Street 2:STE 206 LMC I
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-3100
Practice Address - Country:US
Practice Address - Phone:856-778-4640
Practice Address - Fax:856-778-8862
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04982500174400000X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No174400000XOther Service ProvidersSpecialist
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0123803Medicaid
NJ0123803Medicaid
NJE13252Medicare UPIN