Provider Demographics
NPI:1578822730
Name:CHANNICK, RYAN (MD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:CHANNICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST STE 520
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4430
Mailing Address - Country:US
Mailing Address - Phone:267-606-4478
Mailing Address - Fax:267-339-3761
Practice Address - Street 1:2500 ENGLISH CREEK AVE STE 1300
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-5598
Practice Address - Country:US
Practice Address - Phone:800-321-9999
Practice Address - Fax:267-479-1321
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10209400207QS0010X, 2081S0010X
PAMT2017202081S0010X
PA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program