Healthcare Provider Details

I. General information

NPI: 1528071156
Provider Name (Legal Business Name): RANDALL J RYSER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5770 S 250 E SUITE 445
SALT LAKE CITY UT
84107-8100
US

IV. Provider business mailing address

6360 S 3000 E STE 220
SALT LAKE CITY UT
84121-6924
US

V. Phone/Fax

Practice location:
  • Phone: 801-314-4222
  • Fax: 801-314-4253
Mailing address:
  • Phone: 801-944-3199
  • Fax: 801-944-3186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number163640-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: