Healthcare Provider Details

I. General information

NPI: 1184043283
Provider Name (Legal Business Name): RYAN FILLMORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2014
Last Update Date: 02/14/2023
Certification Date: 02/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWTHORNE LN
CHARLOTTE NC
28204-2515
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-9437
  • Fax: 704-384-9440
Mailing address:
  • Phone: 704-384-9437
  • Fax: 704-384-9440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number155465
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2021-01709
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number2021-01709
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number2021-01709
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: