Provider Demographics
NPI:1720373699
Name:RYAN, MICAH J (MD)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:J
Last Name:RYAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:555 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2136
Mailing Address - Country:US
Mailing Address - Phone:402-280-8100
Mailing Address - Fax:402-280-8103
Practice Address - Street 1:14080 BOYS TOWN HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:BOYS TOWN
Practice Address - State:NE
Practice Address - Zip Code:68010-7513
Practice Address - Country:US
Practice Address - Phone:402-778-6900
Practice Address - Fax:402-778-6917
Is Sole Proprietor?:No
Enumeration Date:2011-06-18
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE27825208000000X
NE6547208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics