Healthcare Provider Details

I. General information

NPI: 1053644179
Provider Name (Legal Business Name): ELIZABETH BOGEL RYAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2009
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 SW NAITO PKWY STE 200
PORTLAND OR
97204-3512
US

IV. Provider business mailing address

111 SW NAITO PKWY STE 200
PORTLAND OR
97204-3512
US

V. Phone/Fax

Practice location:
  • Phone: 888-288-4710
  • Fax: 833-260-2594
Mailing address:
  • Phone: 888-288-4710
  • Fax: 833-260-2594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number272489
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number2024-02178
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberMD218904
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberMD.MD.60239397
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberDR.0070137
License Number StateCO
# 6
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number35.145681
License Number StateOH
# 7
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number272489
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: