Provider Demographics
NPI:1679514186
Name:RYAN AVERETT DPM PC
Entity Type:Organization
Organization Name:RYAN AVERETT DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:AVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-661-0295
Mailing Address - Street 1:1118 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-3217
Mailing Address - Country:US
Mailing Address - Phone:208-667-3585
Mailing Address - Fax:208-666-9214
Practice Address - Street 1:2221 W IRONWOOD CENTER DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2697
Practice Address - Country:US
Practice Address - Phone:208-667-3585
Practice Address - Fax:855-864-8364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP177213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5750710001Medicare NSC
IDU93629Medicare UPIN