Healthcare Provider Details

I. General information

NPI: 1528597044
Provider Name (Legal Business Name): RYAN BROTHERS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32270 TELEGRAPH RD STE 200
BINGHAM FARMS MI
48025-2428
US

IV. Provider business mailing address

32270 TELEGRAPH RD STE 200
BINGHAM FARMS MI
48025-2428
US

V. Phone/Fax

Practice location:
  • Phone: 248-353-0880
  • Fax:
Mailing address:
  • Phone: 248-353-0880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number11008558-1204
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number5101023189
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number5101025916
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: