MEDICARE: MRS. RYAN JESSUP O'LEARY 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	208000000X	Pediatrics Physician	200201293	NC

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

General Provider Information

NPI Number	:	1568548154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. RYAN JESSUP O'LEARY M.D.

Provider Business Mailing Address
First Line	:	17104 PENNINGTON DR
Second Line	:
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-4854
Country	:	US
Telephone Number	:	704-995-2249
Fax Number	:	980-689-5076

Provider Business Practice Location Address
First Line	:	6401 STARGAZE LN
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-0802
Country	:	US
Telephone Number	:	704-591-7196
Fax Number	:	704-464-1818

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

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	04/16/2018

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