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General NPI Number Information
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NPI Number | 1750643235
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Entity Type | Individual
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Provider Name | RYAN MATTHEW OUILLETTE M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/12/2012
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Last Update Date | 02/18/2019
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Provider Practice Location Address
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Address Line | 23550 PARK ST STE 100
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City | DEARBORN
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State | MI
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Zip | 48124-2592
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Country | US
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Telephone | 313-730-0500
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Fax | 313-730-0606
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Provider Business Mailing Address
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Address Line | 23550 PARK ST STE 100
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City | DEARBORN
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State | MI
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Zip | 48124-2592
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Country | US
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Telephone | 313-730-0500
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Fax | 313-730-0606
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XX0005X
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Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
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License Number | 4301111844
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License Number State | MI
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