Provider Demographics
NPI:1881697001
Name:HAELY, RYAN MATTHEW (DC)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:MATTHEW
Last Name:HAELY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6162 CARLYLE DR
Mailing Address - Street 2:
Mailing Address - City:SEVEN HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2920
Mailing Address - Country:US
Mailing Address - Phone:216-986-1806
Mailing Address - Fax:
Practice Address - Street 1:7500 TOWN CENTRE DR
Practice Address - Street 2:STE 300
Practice Address - City:BROADVIEW HTS
Practice Address - State:OH
Practice Address - Zip Code:44147-4009
Practice Address - Country:US
Practice Address - Phone:440-838-5755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2010-08-31
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
OHDC 3160111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2282551Medicaid
OH341958266-001OtherMEDICAL MUTUAL PAYEE NUM
OH341958266-001OtherMEDICAL MUTUAL PAYEE NUM
OH2282551Medicaid
OH350053219Medicare ID - Type UnspecifiedRR MEDICARE PROVIDER NUM