Healthcare Provider Details

I. General information

NPI: 1184828410
Provider Name (Legal Business Name): JOHN GERARD RYAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MALLINCKRODT INSTITUTE OF RADIOLOGY - BARNESJEWISH HOSP 510 SOUTH KINGSHIGHWAY BLVD.,
SAINT LOUIS MO
63110
US

IV. Provider business mailing address

4466 OLIVE ST SUITE #301
SAINT LOUIS MO
63108-1808
US

V. Phone/Fax

Practice location:
  • Phone: 314-533-3161
  • Fax:
Mailing address:
  • Phone: 314-533-3161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number2006028232
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: