Provider Demographics
NPI:1295171056
Name:SANDERSON, RYAN J (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:J
Last Name:SANDERSON
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 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 E COUNTY LINE RD
Practice Address - Street 2:SUITE B
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1079
Practice Address - Country:US
Practice Address - Phone:317-497-6333
Practice Address - Fax:317-497-6334
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01076036A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201168740Medicaid
INP01724113OtherRR MEDICARE
IN201168740Medicaid