Healthcare Provider Details

I. General information

NPI: 1295170231
Provider Name (Legal Business Name): RYAN TIMOTHY BLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2013
Last Update Date: 07/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 OAKLAND DR
KALAMAZOO MI
49008-1282
US

IV. Provider business mailing address

100 THEDA CLARK MEDICAL PLZ STE 400
NEENAH WI
54956-2763
US

V. Phone/Fax

Practice location:
  • Phone: 269-337-4400
  • Fax:
Mailing address:
  • Phone: 920-725-4527
  • Fax: 920-729-2378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number69044
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: