Provider Demographics
NPI:1679667513
Name:RYAN, MARK S (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
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 1:200 NORTH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1561
Mailing Address - Country:US
Mailing Address - Phone:315-787-5100
Mailing Address - Fax:315-787-5108
Practice Address - Street 1:200 NORTH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1561
Practice Address - Country:US
Practice Address - Phone:315-787-5100
Practice Address - Fax:315-787-5108
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164272207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1072637Medicaid
NY164272-7OtherWORKERS COMP
NY102496BJOtherPREFERRED CARE
NYP00003457OtherR.R. MEDICARE
NY2593569OtherGHI
NYP010164272OtherBLUE CROSS
NY102496BJOtherPREFERRED CARE
NYDD4123Medicare PIN