Provider Demographics
NPI:1790721884
Name:RYNICK, STEPHEN A (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:A
Last Name:RYNICK
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 1:1111 MEDICAL CENTER BLVD.
Mailing Address - Street 2:SUITE S750
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072
Mailing Address - Country:US
Mailing Address - Phone:504-340-6976
Mailing Address - Fax:504-349-6786
Practice Address - Street 1:1111 MEDICAL CENTER BLVD.
Practice Address - Street 2:SUITE S750
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072
Practice Address - Country:US
Practice Address - Phone:504-340-6976
Practice Address - Fax:504-349-6786
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018522208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1363359Medicaid
52572B422Medicare PIN
LA1363359Medicaid
LA52572B422Medicare ID - Type Unspecified