Healthcare Provider Details

I. General information

NPI: 1013411180
Provider Name (Legal Business Name): RYAN MICHAEL BART DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 11/09/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10TH MEDICAL GROUP 4102 PINION DR
USAF ACADEMY CO
80840
US

IV. Provider business mailing address

2355 FACULTY DR
USAF ACADEMY CO
80840-1805
US

V. Phone/Fax

Practice location:
  • Phone: 719-333-5180
  • Fax:
Mailing address:
  • Phone: 719-333-5180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2080
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2080
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: