Provider Demographics
NPI:1891970893
Name:GORDON A.RYAN,MD PC
Entity Type:Organization
Organization Name:GORDON A.RYAN,MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR.
Authorized Official - Prefix:MRS
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:R
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:RMA
Authorized Official - Phone:757-624-9433
Mailing Address - Street 1:400 GRESHAM DR
Mailing Address - Street 2:SUITE 411
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1901
Mailing Address - Country:US
Mailing Address - Phone:757-624-9433
Mailing Address - Fax:757-624-6884
Practice Address - Street 1:400 GRESHAM DR
Practice Address - Street 2:SUITE 411
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1901
Practice Address - Country:US
Practice Address - Phone:757-624-9433
Practice Address - Fax:757-624-6884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034688174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005878900Medicaid
C47264Medicare UPIN
VA005878900Medicaid