Healthcare Provider Details

I. General information

NPI: 1023000882
Provider Name (Legal Business Name): JOHN B RYAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11012 E 13 MILE RD STE 201
WARREN MI
48093-2547
US

IV. Provider business mailing address

11012 E 13 MILE RD STE 201
WARREN MI
48093-2547
US

V. Phone/Fax

Practice location:
  • Phone: 586-582-0864
  • Fax: 586-582-0964
Mailing address:
  • Phone: 586-582-0864
  • Fax: 586-582-0964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number4301068798
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: