Provider Demographics
NPI:1932507464
Name:RYAN ROLF MD LLC
Entity Type:Organization
Organization Name:RYAN ROLF MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROLF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-633-1950
Mailing Address - Street 1:129 OSPREY PASS
Mailing Address - Street 2:
Mailing Address - City:HUNTERTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46748-9231
Mailing Address - Country:US
Mailing Address - Phone:260-633-1950
Mailing Address - Fax:
Practice Address - Street 1:129 OSPREY PASS
Practice Address - Street 2:
Practice Address - City:HUNTERTOWN
Practice Address - State:IN
Practice Address - Zip Code:46748-9231
Practice Address - Country:US
Practice Address - Phone:260-633-1950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-16
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057615A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201277720 AMedicaid
IN201277720 AMedicaid