Healthcare Provider Details

I. General information

NPI: 1417691866
Provider Name (Legal Business Name): RYLAN HOLMBERG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 UNIVERSITY HOSPITAL DR RM 714
MOBILE AL
36617-2300
US

IV. Provider business mailing address

2451 UNIVERSITY HOSPITAL DR RM 714
MOBILE AL
36617-2300
US

V. Phone/Fax

Practice location:
  • Phone: 251-471-7152
  • Fax:
Mailing address:
  • Phone: 251-471-7152
  • Fax: 251-471-7008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: