Provider Demographics
NPI:1841772803
Name:WHITEHOUSE, RYAN MICHAEL (MPT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:WHITEHOUSE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 PARK ST
Mailing Address - Street 2:
Mailing Address - City:EAST MILLINOCKET
Mailing Address - State:ME
Mailing Address - Zip Code:04430-1132
Mailing Address - Country:US
Mailing Address - Phone:207-447-1510
Mailing Address - Fax:
Practice Address - Street 1:200 SOMERSET ST
Practice Address - Street 2:
Practice Address - City:MILLINOCKET
Practice Address - State:ME
Practice Address - Zip Code:04462-1258
Practice Address - Country:US
Practice Address - Phone:207-723-5161
Practice Address - Fax:207-723-3008
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2574208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation