MEDICARE: DR. COLLEEN MARIE RYAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	J8752	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	J8752	OTHER	TX	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1518967041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. COLLEEN MARIE RYAN MD

Provider Business Mailing Address
First Line	:	814 MUIRFIELD RD
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76248-8228
Country	:	US
Telephone Number	:	817-514-7002
Fax Number	:	--

Provider Business Practice Location Address
First Line	:	814 MUIRFIELD RD
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76248-8228
Country	:	US
Telephone Number	:	817-514-7002
Fax Number	:	--

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2005
Last Update Date	:	07/08/2007

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