Provider Demographics
NPI:1396872263
Name:POLSELLI, RYAN JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:JOSEPH
Last Name:POLSELLI
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 1:3982 WOODLAND RETREAT BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4593
Mailing Address - Country:US
Mailing Address - Phone:445-465-8718
Mailing Address - Fax:
Practice Address - Street 1:3982 WOODLAND RETREAT BLVD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34655-4593
Practice Address - Country:US
Practice Address - Phone:844-546-5871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 121176208D00000X, 2085R0202X
FLME121176261QR0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No261QR0207XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003112633AMedicaid
GA202I300112Medicare PIN