Healthcare Provider Details

I. General information

NPI: 1073045274
Provider Name (Legal Business Name): EMILY RYAN-MICHAILIDIS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 GREEN ST
ROSWELL GA
30075-3609
US

IV. Provider business mailing address

650 PONCE DE LEON AVE STE. 300 #1635
ATLANTA GA
30308
US

V. Phone/Fax

Practice location:
  • Phone: 201-654-6397
  • Fax: 314-405-9284
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number90254
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: