Healthcare Provider Details

I. General information

NPI: 1235392523
Provider Name (Legal Business Name): RYAN JACKSON CORLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 EAST BLVD
CHARLOTTE NC
28203-5203
US

IV. Provider business mailing address

PO BOX 535432
ATLANTA GA
30353-6220
US

V. Phone/Fax

Practice location:
  • Phone: 954-384-0175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number66585
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number2012-00769
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: