MEDICARE: RYAN J BORTOLON 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	207L00000X	Anesthesiology Physician	46172	MN

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	:	1831178623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN J BORTOLON M.D.

Provider Business Mailing Address
First Line	:	P.O. BOX 209036
Second Line	:	SHRINERS HOSPITALS FOR CHILDREN TWIN CITIES
City	:	DALLAS
State	:	TX
Zip	:	75320-9036
Country	:	US
Telephone Number	:	813-281-8478
Fax Number	:	813-281-8113

Provider Business Practice Location Address
First Line	:	2025 E RIVER PARKWAY
Second Line	:	SHRINERS HOSPITALS FOR CHILDREN TWIN CITIES
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55414-3604
Country	:	US
Telephone Number	:	612-596-6187
Fax Number	:	612-339-7634

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

Provider Enumeration Date	:	01/11/2006
Last Update Date	:	03/29/2011

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