=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750724688
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN DAVID MCCONN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2013
-----------------------------------------------------
Last Update Date | 07/18/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5496 E TAFT RD
-----------------------------------------------------
City | N SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-552-6700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5824 WIDEWATERS PKWY
-----------------------------------------------------
City | EAST SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13057-3072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-251-3105
-----------------------------------------------------
Fax | 315-552-6018
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 288336
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------