Provider Demographics
NPI:1295170231
Name:BLY, RYAN TIMOTHY (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:TIMOTHY
Last Name:BLY
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 1:100 THEDA CLARK MEDICAL PLZ
Mailing Address - Street 2:STE 400
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2763
Mailing Address - Country:US
Mailing Address - Phone:920-725-4527
Mailing Address - Fax:920-729-2378
Practice Address - Street 1:1000 OAKLAND DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1282
Practice Address - Country:US
Practice Address - Phone:269-337-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-03
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69044208600000X
MI4301102644390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery