Healthcare Provider Details

I. General information

NPI: 1497750855
Provider Name (Legal Business Name): MICHAEL HUNTER RYAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 SOUTHRIDGE DR STE B
JEFFERSON CITY MO
65109-4005
US

IV. Provider business mailing address

1620 SOUTHRIDGE DR STE B
JEFFERSON CITY MO
65109-4005
US

V. Phone/Fax

Practice location:
  • Phone: 573-632-2780
  • Fax: 573-632-2782
Mailing address:
  • Phone: 573-632-2780
  • Fax: 573-632-2782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number118143
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number118143
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: