Provider Demographics
NPI:1851360192
Name:RYAN, JACQUELINE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
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:PO BOX 64916
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4916
Mailing Address - Country:US
Mailing Address - Phone:443-481-6573
Mailing Address - Fax:444-481-6515
Practice Address - Street 1:11116 MEDICAL CAMPUS RD
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6710
Practice Address - Country:US
Practice Address - Phone:301-790-8804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0057078207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0017OtherCAREFIRST BCBS
MD7539450OtherAETNA PPO
MD3112374OtherAETNA HMO
MD61003502OtherCAREFIRST BCBS
MD110243912OtherRR MEDICARE
MD827402900Medicaid