Provider Demographics
NPI:1811195712
Name:KLANSECK, RYAN STEPHEN (DO)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:STEPHEN
Last Name:KLANSECK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:MI
Mailing Address - Zip Code:49084-0158
Mailing Address - Country:US
Mailing Address - Phone:126-935-7119
Mailing Address - Fax:
Practice Address - Street 1:3901 STONEGATE PARK STE F
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9137
Practice Address - Country:US
Practice Address - Phone:810-624-1586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P31360061Medicare PIN