Healthcare Provider Details

I. General information

NPI: 1235396045
Provider Name (Legal Business Name): RYAN NIEHAUS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 S CLARIZZ BLVD
BLOOMINGTON IN
47401-5588
US

IV. Provider business mailing address

PO BOX 1329
BLOOMINGTON IN
47402-1329
US

V. Phone/Fax

Practice location:
  • Phone: 812-353-3060
  • Fax:
Mailing address:
  • Phone: 812-353-3087
  • Fax: 812-353-5859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number02004042A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: