Provider Demographics
NPI:1851824270
Name:GARY, MICHAEL RYAN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RYAN
Last Name:GARY
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 1:970 LAKELAND DR STE 61
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4682
Mailing Address - Country:US
Mailing Address - Phone:601-982-7850
Mailing Address - Fax:601-366-8507
Practice Address - Street 1:970 LAKELAND DR STE 61
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4682
Practice Address - Country:US
Practice Address - Phone:601-982-7850
Practice Address - Fax:601-366-8507
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-3339207R00000X
MS27091207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08653039Medicaid