Healthcare Provider Details

I. General information

NPI: 1962085035
Provider Name (Legal Business Name): RYAN FOGG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 05/05/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VCUHS DEPT OF UROL RESIDENCY, 980118 1250 E. MARSHALL STREET
RICHMOND VA
23298-0118
US

IV. Provider business mailing address

VCUHS GMEA PO BOX 980257
RICHMOND VA
23298-0257
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-8146
  • Fax:
Mailing address:
  • Phone: 804-828-9783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: