MEDICARE: CHARLES G RYAN JR. M.D.

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	207V00000X	Obstetrics & Gynecology Physician	24170	TN
2	207V00000X	Obstetrics & Gynecology Physician	16676	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	6007056	OTHER	TN	BCBS

General Provider Information

NPI Number	:	1548263627
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES G RYAN JR. M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1000
Second Line	:	DEPT # 978
City	:	MEMPHIS
State	:	TN
Zip	:	38148-0001
Country	:	US
Telephone Number	:	662-890-5559
Fax Number	:	662-893-8323

Provider Business Practice Location Address
First Line	:	6819 CRUMPLER BLVD STE 101
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-1941
Country	:	US
Telephone Number	:	662-890-5559
Fax Number	:	662-893-8323

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

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	10/19/2018

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