Provider Demographics
NPI:1043338833
Name:RYAN, MARK THOMAS (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:RYAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25625 SCHOENHERR RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-1499
Mailing Address - Country:US
Mailing Address - Phone:586-759-4700
Mailing Address - Fax:
Practice Address - Street 1:25625 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-1451
Practice Address - Country:US
Practice Address - Phone:586-759-4700
Practice Address - Fax:586-759-1504
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016208207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI200E009780OtherBCBSM/BCN
MIN65730030Medicare PIN