Healthcare Provider Details

I. General information

NPI: 1659910800
Provider Name (Legal Business Name): MICHAEL RYAN OLDENBURG NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2020
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 TOWER RD NE STE 200
MARIETTA GA
30060-9412
US

IV. Provider business mailing address

677 CHURCH ST NE
MARIETTA GA
30060-1101
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-1372
  • Fax:
Mailing address:
  • Phone: 770-793-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberRN259503
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN259503
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: