Healthcare Provider Details

I. General information

NPI: 1578589255
Provider Name (Legal Business Name): JOHN MICHAEL RYDEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8373 UNITY DR
VIRGINIA MN
55792-4005
US

IV. Provider business mailing address

8373 UNITY DR
VIRGINIA MN
55792-4005
US

V. Phone/Fax

Practice location:
  • Phone: 218-748-7480
  • Fax: 218-748-7488
Mailing address:
  • Phone: 218-748-7480
  • Fax: 218-748-7488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40514
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: