Healthcare Provider Details

I. General information

NPI: 1427106061
Provider Name (Legal Business Name): RYAN FOOT & ANKLE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 RANDOLPH RD
CHARLOTTE NC
28207-1126
US

IV. Provider business mailing address

2200 RANDOLPH RD
CHARLOTTE NC
28207-1126
US

V. Phone/Fax

Practice location:
  • Phone: 704-376-3947
  • Fax: 704-376-3947
Mailing address:
  • Phone: 704-376-3947
  • Fax: 704-376-9487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number450
License Number StateNC

VIII. Authorized Official

Name: DR. JEFFREY J GLASER
Title or Position: ASSOCIATE
Credential:
Phone: 704-376-3947