Provider Demographics
NPI:1295765337
Name:RYAN, LORETTA A (MD)
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:A
Last Name:RYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1434 CHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1947
Mailing Address - Country:US
Mailing Address - Phone:765-966-5527
Mailing Address - Fax:765-966-5527
Practice Address - Street 1:1434 CHESTER BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1947
Practice Address - Country:US
Practice Address - Phone:765-966-5527
Practice Address - Fax:765-966-5527
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048837A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200190240OtherMANAGED HEALTH SERVICES
OH2178567Medicaid
IN200190240Medicaid
IN00000082701OtherANTHEM
IN351265355OtherTAX ID
IN351265355OtherTAX ID
IN902290NMedicare PIN
IN200190240Medicaid