Healthcare Provider Details

I. General information

NPI: 1548263627
Provider Name (Legal Business Name): CHARLES G RYAN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6819 CRUMPLER BLVD STE 101
OLIVE BRANCH MS
38654-1941
US

IV. Provider business mailing address

PO BOX 1000 DEPT # 978
MEMPHIS TN
38148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 662-890-5559
  • Fax: 662-893-8323
Mailing address:
  • Phone: 662-890-5559
  • Fax: 662-893-8323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number24170
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number16676
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: