Provider Demographics
NPI:1831178623
Name:BORTOLON, RYAN J (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:J
Last Name:BORTOLON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:P.O. BOX 209036
Mailing Address - Street 2:SHRINERS HOSPITALS FOR CHILDREN TWIN CITIES
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-9036
Mailing Address - Country:US
Mailing Address - Phone:813-281-8478
Mailing Address - Fax:813-281-8113
Practice Address - Street 1:2025 E RIVER PARKWAY
Practice Address - Street 2:SHRINERS HOSPITALS FOR CHILDREN TWIN CITIES
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3604
Practice Address - Country:US
Practice Address - Phone:612-596-6187
Practice Address - Fax:612-339-7634
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2011-03-29
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Provider Licenses
StateLicense IDTaxonomies
MN46172207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN380440200Medicaid
H88100Medicare UPIN
MNP00106293Medicare ID - Type UnspecifiedRAILROAD
MN050001678Medicare ID - Type Unspecified